“And put a knife to thy throat, if thou be a man given to appetite.” Proverbs 23:2

Worldwide, causes of death are complex, ranging from accidents, disease, infections, drug use including alcohol and tobacco, toxins from pollution, malnutrition. . . and the list goes on. In general, causes of death are attributed to either the aging process, to circumstances, or to lifestyle choices. In countries with low-income economies, more than half the deaths were caused by communicable diseases, maternal causes, conditions arising during pregnancy and childbirth, and nutritional deficiencies. In countries with high-income economies, the leading causes of death were related to age and lifestyle, including heart disease, strokes, Alzheimer’s, and certain cancers.

The World Health Organisation (WHO) classifies death according to the disease or injury which caused the death.  However, causes of death can also be categorized according to the risk factors that can contribute to death.  These risk factors may range from smoking, to unhealthy diets, to reckless driving, income levels, lack of access to medical care including vaccinations, physical inactivity and many others. Many of these risk factors are within the control of the individual person and are considered “preventable” risk factors, which can contribute to the death of that individual. These preventable risk factors can also lead to a number of diseases. Each year, nearly 900,000 Americans die prematurely from the five leading causes of death (heart disease, cancer, chronic lung disease, accidents, stroke)—yet 20 percent to 40 percent of the deaths from each cause arise from preventable, or also referred to, modifiable risk factors.

Let us look at the top risk factors that contribute to disease and death. Tobacco use is considered the number one risk factor when it comes to preventable deaths. We know that tobacco use leads to lung cancers, emphysema, chronic obstructive pulmonary (lung) disease (COPD), heart disease, strokes, diabetes—and this is not the full list.

And, what is the second risk factor? In many countries, obesity is listed as the second most prevalent risk factor in preventable death. The reason that obesity now ranks second is the high numbers of people who are now obese. Obesity rates are rising. Since 1975, the number of people worldwide who are obese has nearly tripled.  And it is proven that obesity leads to many other diseases which are significant for their morbidity (causing sickness) and mortality (causing death). Several countries now list obesity as a disease because of the health impact that it has on those who are obese.

This article will focus on obesity, as it is becoming a significant health issue, not only in the richest countries, but in developing countries also. Overweight and obesity are linked to more deaths worldwide than underweight. Globally there are more people who are obese than underweight—this occurs in every region except parts of sub-Saharan Africa and Asia.

Let us first look at some numbers. In 2016, more than 1.9 billion adults worldwide, 18 years and older, were overweight. Of these, over 650 million were obese. If we look at percentages, 39% of adults aged 18 years and over were overweight in 2016, and 13% were obese. These numbers vary from country to country; however, most of the world’s population lives in countries where overweight and obesity kills more people than underweight. The number of overweight children is even more alarming. 41 million children under the age of 5 were overweight or obese in 2016. Over 340 million children and adolescents aged 5–19 were overweight or obese in 2016. The rise in overweight and obesity in the age category of 5-19 has risen from just 4% in 1975 to just over 18% in 2016. The rise has occurred similarly among both boys and girls: in 2016, 18% of girls and 19% of boys were overweight.

In 1975 1% of those in ages 5-19 were obese. In 2016 this has increased to 6% of girls and 8% of boys. Children are not immune to developing diseases caused by obesity. Many children and adolescents who are overweight and obese are starting to show signs of heart disease from an early age.

How do we determine if someone is underweight, normal weight, overweight, or obese? Of course we can look at someone and have a good idea where they may fall in the four categories. Because obesity has been recognized as a particular health problem in itself, even more so than just being overweight, knowing if someone is obese is important; this provides the health professional with the opportunity to assess for health problems directly associated with obesity. The BMI (Body Mass Index) has been widely used to determine which of the four categories someone’s weight falls into. This is a calculation based on the combination of height and weight. There are graphs available on the internet that can be used to calculate BMI values. The limitations of the BMI are that it cannot determine the percentage of body fat, and it is also inaccurate in people who have a lot of muscle. A BMI score of 30 or above indicates obesity. (See the graph).

An effective alternative to the BMI is to measure the circumference of someone’s waist. This gives a good indication of the amount of abdominal fat someone is carrying. Knowing the circumference of someone’s waist can help determine the risk of heart disease and other medical conditions. The following figures indicate individuals in the “at risk” group: women with a waist circumference of 90 cm (35 inches) and over, and men with a waist circumference of 102 cm (40 inches) and over.

The waist-to-hip ratio is also an excellent way of calculating how much excess weight someone is carrying. To calculate this ratio, use a tape measure and take a reading from the natural waist line and the widest part of the hips. Now divide the circumference of the waist by the hip circumference measurement. The World Health Organisation determines that abdominal obesity is represented by a waist–hip ratio above 0.90 for males and above 0.85 for females.

The key fact to know when it comes to obesity is that, for the most part, it is preventable. A fundamental cause of obesity and overweight is an energy imbalance between calories consumed and calories expended. To put it simply, obesity develops because the amount of calories taken in exceed the needs of the body. Therefore, many aspects of obesity are controllable through diet and exercise. However, it is not always this simple. Many scientists have weighed in on this topic and recognize that people who are obese, who have an increased accumulation of fat, are not just eating too many calories or lacking physical exercise; history of obesity; this risk is two to eight times higher as opposed to a person with no family history of obesity. The risk is even higher in cases of severe obesity. Whether

this is due to genetics or learned lifestyle patterns is not always known. Current knowledge concludes that genetic factors may be involved in causing obesity; and that these genes probably interact with environment factors, such as food intake and physical activity in increasing the risk of obesity.

Overall, obesity is related to genetic, psychological, physical, metabolic, neurological, and hormonal impairments. People who are obese can have disorders in the body’s signals that trigger feelings of hunger and fullness. Efforts to lose weight is difficult, and often people regain all the weight lost within months or years. This is caused by a slower and less efficient metabolic rate once weight is reduced. Once a person has been overweight, the body automatically tries to return to its previous weight. And finally, the food industry markets products that include high levels of fats and sugars, and are extremely inviting and tasty, keeping people craving more of these foods, regardless of whether they are hungry or not.

Obesity is one of the few conditions that can negatively influence social and interpersonal relationships. There continues to be a stigma around obesity; those who obese are considered lazy, unsuccessful, unintelligent, lack self-discipline, have poor willpower, and are choosing to be noncompliant with weight-loss treatments. Obese people are viewed as personally responsible for their weight problems. The current message in society is that both the cause and the solution for obesity reside within the individual person.

Weight stigma remains socially acceptable, therefore negative attitudes toward obese persons include employers, coworkers, teachers, physicians, nurses, medical students, dietitians, psychologists, peers, friends, family members, and even in children aged as young as three years. This social stigma leads to social exclusion and isolation, lower income levels due to discrimination in the workplace, decreased academic performance due to bullying in schools, and inadequate health care due to biases among health professionals. All these taken together impact a person’s overall physical and mental health.

Recent estimates suggest that the prevalence of weight discrimination has increased by 66% over the past decade, and is now comparable to the rates of racial discrimination in America. Some think that this discrimination is useful, as it may motivate obese people to adopt healthier lifestyles. Unfortunately, this assumption is not true. If weight stigma promoted healthier lifestyles and subsequent weight loss, then the increase in weight stigma over the past few decades should have been accompanied by a reduction in obesity rates; instead there has been an alarming increase in overweight people. Research also shows that weight stigma increases the likelihood of engaging in unhealthy eating behaviours as a way of coping, and lower levels of physical activity, both of which exacerbate obesity and weight gain. In fact, teaching people to develop ways of coping with weight stigma can lead to improved weight loss.  But, how do we educate the public to change these negative stereotypes?

Factors leading to the increase in obesity include advancements in technology, and the reduction in jobs requiring manual labour, leading to decreased energy expenditure. We need to use less energy to do our jobs, and to maintain our households. The structure of environments have decreased the opportunity for healthy lifestyles, with the design of cities, making them less favourable for walking, including reduced feelings of safety, the increase in public transportation, the amount and easy accessibility to food stores and restaurants.

The food industry has increased our ability to access inexpensive, but calorie-dense foods and beverages. At the same time, costs for fresh fruits, vegetables, and other whole foods have increased in price. This had led to a greater consumption of unhealthy foods. Extensive marketing by the food industry also leads to overconsumption of these unhealthy, fat and sugar laden, high-calorie products. Much of this marketing is geared towards children, which starts them early on the road to excessive weight gain.

Environmental changes which contribute to the rise in levels of obesity have increased faster than the recognition of the many factors, including biological and genetic, that play a part in maintaining a healthy weight. Also lagging behind are strategies to combat the environmental changes that are leading to increases in overweight and obese individuals.

Overweight and obesity are no longer just considered a high-income country problem, as both are on the rise in low- and middle-income countries, particularly in urban settings. In Africa, the number of overweight children under 5 has increased by nearly 50 per cent since 2000. Nearly half of the children under five years of age who were overweight or obese in 2016 lived in Asia. Obesity is rising; however, the nutritional status has not changed. People are eating more, their weight is increasing; however, the food they eat is unhealthy. Studies indicate that during the last 30 years, there are significant changes in average body weight, diet, and physical activity, occurring alongside economic development in developing countries. Lifestyle and environmental factors are acting together to fuel the obesity epidemic. If we look at the example of Africa, the epidemic of obesity can in part be explained by decreased levels of physical activity as far back as the late 1980s; roads were tarred, taxis and buses became the most common transport means and, in addition, there was an ongoing trend away from manual labour to less physically strenuous jobs and the shift to less nutrient-dense diets.

As evidence mounts on the impact of obesity worldwide, along with a significant increase in preventable sickness and death, and the impact on world economies and overall health of the population, several prominent medical and health organizations, including the American Medical Association (AMA) and the Canadian Medical Association (CMA), have declared obesity a chronic disease. The numbers in these countries is alarming. Canada has determined that the financial burden of obesity represents $3.96 billion dollars a year on the Canadian economy. It is expected to surpass smoking as the leading cause of sickness and death. In the United States, the estimated annual health care costs of obesity-related illness are $190.2 billion or nearly 21% of the annual medical spending in the United States. Childhood obesity alone is responsible for $14 billion in direct medical costs.

More globally, the World Health Organization has developed the “WHO Global Strategy on Diet, Physical Activity and Health” and describes the actions needed to support healthy diets and regular physical activity. The Strategy calls upon all stakeholders to take action at global, regional and local levels to improve diets and physical activity patterns at the population level in an effort to reduce the risk of overweight and obesity, and its subsequent health effects.

Also, in 2016, the United Nations created 17 Sustainable Development Goals (SDG), which were approved by all world leaders. Sustainable development calls for “concerted efforts towards building an inclusive, sustainable and resilient future for people and the planet.” Included in these SDG’s is a statement acknowledging that overconsumption of food is detrimental to our health and the environment, and that 2 billion people globally are overweight or obese.

What is the benefit of referring to obesity as a disease? It is important for health care providers to recognize obesity as a disease so preventive measures can be put in place and patients can receive the appropriate treatment,” said CMA President Cindy Forbes. Recognizing obesity as a disease may precipitate a shift in thinking of obesity as just a lifestyle choice to a medical disease with an obligation to treat it as other diseases. Despite the increase in evidence of the effects of obesity on an individual’s health, the debate continues. Is obesity a disease? For some, obesity as a disease invalidates the importance of discipline, proper nutrition, and exercise and enables individuals with obesity to escape responsibility. For others, obesity as a disease is a bridge to additional research, coordination of effective treatment, and increased resources for weight loss.

Adherents of obesity as a disease state that it meets the definition because it decreases life expectancy and impairs normal functioning of the body. Reluctance on the behalf of the medical profession to treat obesity as a disease is the fear that doctors will be overwhelmed with the numbers of obese people in their practice, and the challenge of finding adequate and timely treatments for these people.

Understanding that the disease of obesity is most often caused by modifiable risk factors, awareness will lead to changes in perception as to the causes of obesity, in individuals, health professionals and governments. This then can lead to an increase in collaborative efforts to reverse the obesity epidemic. It is governments, not individuals that have the ability to change the food environment by regulating industries, implementing taxes, and controlling availability and affordability of food products—healthy foods need to be cheaper, and readily accessible, whereas unhealthy foods need to have added “sin taxes”, which can go directly into funding healthy programs for weight loss. Governments can also influence and promote changes to physical activity of its people by making changes and improvements in infrastructures, such as making cities more bicycle friendly, improving access to leisure facilities, or legislating employers to reduce sedentary work practices. Until obesity is universally recognized as a chronic disease, and not just a lifestyle choice, its prevalence will continue to increase at exponential rates. Awareness of the problem is the first step to finding sustainable solutions.

“It is sin to be intemperate in the quantity of food eaten, even if the quality is unobjectionable.” –Counsels on Diet and Foods, p. 102