Content uploaded by Laurie Twells
Author content
All content in this area was uploaded by Laurie Twells
Content may be subject to copyright.
Obesity in Newfoundland
and Labrador
Laurie Twells
September, 2005
A Report by the Newfoundland and Labrador
Centre for A
pp
lied Health Research
2
Table of Contents
Obesity .....................................................................................................................3
Epidemiology of obesity .............................................................................................3
What is obesity and how is it measured?.....................................................................5
Health consequences of obesity..................................................................................6
Tracking for obesity ...............................................................................................7
Causes for the increasing prevalence of obesity...........................................................7
Determinants of obesity .......................................................................................10
Obesity and Health Services Utilization Patterns.........................................................10
Epidemiology of obesity in NL...................................................................................11
Obesity in the NL Health Boards ...............................................................................14
Is obesity a preventable condition?...........................................................................15
Local Prevention Efforts ...........................................................................................16
What is the medical treatment for obesity?................................................................17
Local Treatment Options ..........................................................................................18
Conclusions and Discussion......................................................................................19
Bibliography ............................................................................................................21
3
Obesity
Obesity is described as an “epidemic” by the World Health Organization due to its
increasing world-wide prevalence over a relatively short time period (1). Obesity is the
most common metabolic condition in economically developed countries (2) and is
considered to be the second leading avoidable cause of mortality for adults in Western
countries after smoking (3).
Over the past two decades there has been a significant increase in the prevalence of
obesity in the Canadian population as measured by body mass index (BMI). According to
the National Population Health Survey (NPHS 1994) and the Canadian Community
Health Survey (CCHS 2003), approximately 15% of Canadian adults aged 20-64 years
were classified as obese, compared to 13% for the same population in 1994. In Canada
the annual cost of health care related to over-weight and obesity-related conditions in
adults has been estimated to be between $1.8 and $3.5 billion and this estimate does
not include children (2).
Epidemiology of obesity
In Canada, between 1985 and 2003 the prevalence of adult obesity increased three-fold.
In 1985, according to the Health Promotion Survey, approximately 5.6% of the adult
population aged 20-64 years was classified as obese. According to the Canadian
Community Health Survey, in 2003, 14.9% of Canadians in this same age-range were
considered obese (Figure 1). Increases in the prevalence of obesity in Canada are
comparable to other western developed countries, although Canada does have slightly
lower rates than both the United States and the United Kingdom (Figure 2). Over this
same time period, there has been a significant increase in the prevalence of obesity in
Canadian children. A study by Tremblay et al. (4) examined the prevalence of
overweight and obese children, using three national surveys administered between 1981
and 1996. The study concluded that between1981-1996 the percentage of overweight
boys increased from 15% to 29% and the percentage of overweight girls increased from
15% to 24%. During the same period the prevalence of obesity increased from 5% to
13% for boys and from 5% to 11.8% for girls (Figure 3). A study by Willms in 2003
found a similar prevalence for overweight and obese children: 33% of boys and 26% of
4
girls measured overweight and 10% of boys and 9% of girls measured obese. These
findings suggest that over a 15-year period the prevalence of childhood overweight and
obesity has more than doubled, although there are no statistically significant differences
between boys and girls (5).
Source: P.T. Katzmarzyk, Unpublished Results.
Data from: Statistics Canada. Health Indicators, June, 2004.
No Data <10% 10%-14% 15-19% ≥20%
Cdn.: 15%
NF&L: 21%
Prevalence of obesity in Canada 2003
Fi
g
ure 1
Prevalence of Obesity
0
5
10
15
20
25
1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004
year
%
Canada
U.S.
UK
Fi
g
ure 2
Sources: CFS
,
NPHS
,
CCHS
,
BRFSS
5
% overweight and obese in Canada
0
5
10
15
20
25
boys girls boys girls
%
1981
1996
overweight
obese
Tremblay MS. et al.
International Journal of Obesity Research, 2002
What is obesity and how is it measured?
Obesity is characterized by excessive adipose tissue or “body fat” caused primarily by an
imbalance between energy intake and expenditure. Body fat can be measured many
ways; however the most common non-invasive method is through the calculation of the
body mass index (BMI). To calculate a BMI, an individual’s height and weight are
required. Using these numbers, an index is calculated by dividing weight in kilograms by
height in meters squared (kg/m2). There is a wide body of research that links increasing
body mass index with increasing morbidity and mortality (6; 7). At either very low or
very high values, BMI is associated with increasing health risk in terms of increased risk
of mortality. As a result the World Health Organization (WHO) in collaboration with the
International Obesity Task Force (IOTF) designed a classification system to separate
BMI values into 4 main categories that correlate with increasing health risk. These
categories and associated health risks are:
BMI (kg/m2) Descriptor Risk of co-morbidities
<18.5 underweight Increased risk
18.5 – 24.9 Normal weight Low risk
25 – 29.9 Overweight Increased risk
>30 Obese Moderate-very severe risk
Fi
g
ure 3
6
The “J” or “U” shaped graph below is typical of the associated increased health risk, with
either
increasing or decreasing BMI values (Figure 4). According to a study by Calle (6),
as body mass index increases the relative risk of death by cardiovascular disease,
cancers and all other causes increases. At a BMI of over 40 (described as morbidly
obese), an individual is almost twice as likely to die from cardiovascular disease as a
“normal weight” individual (BMI <25kg/m2).
Relationship Between BMI and
Mortality in Women
Calle et al., N Engl J Med 1999;341:1097-105
Health consequences of obesity
Excessive “body fat” in adults can lead to adverse metabolic effects on blood pressure,
cholesterol, triglycerides and insulin resistance. It also impairs the functioning of many
important organs and body systems, increasing the risk of developing multiple health
problems, and the likelihood of early death (7; 8). More specifically, obesity is associated
with health problems such as cardiovascular disease (9; 10; 11), many cancers,
especially those hormonally driven, gallbladder disease, and Type 2 diabetes (12). In
addition, obese individuals suffer social stigmatization, discrimination and psychological
consequences (13; 14).
Fi
g
ure 4
7
Several studies on obesity in children show an association between “excessive body fat”
and adult-like cardiovascular risk factors, such as high blood pressure, dyslipidemia,
abnormalities in left ventricular mass, hyperinsulinemia and/or insulin resistance (15;
16). In a study by Freedman et al. 58% of obese 5-10 year olds had at least one of
these five cardiovascular risk factors and 25% had two or more. A systematic review of
cardiovascular/obesity research concluded that childhood obesity is associated with
adverse effects on the cardiovascular system, which are well known and similar to
effects in adults (17). Obesity in childhood is associated with an increased incidence of
asthma (18; 19). In addition, childhood obesity is associated with an increasing risk of
type II diabetes(10;26), a disease that, until recently, was diagnosed only in adults.
Obese children are more likely to experience psychological problems than their non-
obese peers. Girls are more at risk than boys and psychological morbidity increases with
age. Low self esteem and behavioral problems are associated with obesity (13; 21).
Several studies have concluded that obesity in childhood/adolescence has adverse
effects on long-term social and economic outcomes in young adulthood such as level of
income and educational attainment (22; 23).
Tracking for obesity
Obese children are more likely to become obese adults (1; 24; 25). According to the
National Population Health Survey, a longitudinal survey of Canadians, between 1993/94
and 2002/03, one out of four overweight individuals had become obese; one out of
three normal weight individuals had become overweight and only one in ten initially in
the overweight range moved into the normal range. This Canadian data provides
evidence for other research in this area and confirms that obesity “tracks” through life.
Once excess weight is gained it is very difficult to lose.
Causes for the increasing prevalence of obesity
Health professionals and researchers agree that a proportion of obesity in the population
is due to an inherited genetic predisposition and factors outside an individual’s control. It
is purported that between 20-40% of the cases of obesity may be explained by genetics
(G Sun, 2004). The tracking and surveillance of this relatively recent (<25 years)
increase in obesity prevalence in developed countries, suggests that it is unlikely that
genetics is the main contributor to the change in mean body weight (26; 27). Changing
8
lifestyles (social, behavioral, cultural, community) which promote an imbalance of
energy intake and energy expenditure in most societies in the world are more likely to
be the cause (Finegood, 2004). Although genetics research is crucial to understanding
the root biological and genetic causes of obesity in order to inform treatment options,
research on the burden of obesity and effective interventions to manage, prevent and
reduce obesity is equally important. A synthesis paper by the Canadian Institutes of
Health Research (CIHR) concluded that “obesity is a multi-factorial problem” and many
factors are both associated with and predict obesity, including individual lifestyle
choices, community structure, societal values, and public policy. The International
Obesity Task Force published a framework to illustrate how many levels of a society,
including the global environment can influence the prevalence of obesity at a population
level (Figure 5). It is most likely a combination of these factors that promote an
energy/expenditure imbalance in societies today. According to this framework, to have
an impact on the prevalence of overweight or obesity in a population, policy makers
need to identify and implement programs and policies that target different levels of
influence (local, community, global). Introducing mandatory physical education classes
and healthy food choices in schools; providing infrastructure for bike lanes, safe places
to walk, recreation areas; and partnering with food manufactures to ensure food
products low in fat, sugar and salt are available at affordable prices are examples of
intervention efforts designed to have an impact on several levels of influence.
9
International
factors
National
Regional
Community
Local
Work
School
Home
Individual
Population
Figure 5
“Causal Web”
Public
transport Leisure
activities
Energy
output
%
Overweight
or obese
Energy
intake
labour
infections
worksite
Family
home
School
Activity
Public
safety
sanitation
Agriculture/
Local
markets
healthcare
Manufact-
ured food
Development
Globalization
of markets
Media
transport
urbanization
health
Social security
Media
education
Food/
nutrition
10
Determinants of obesity
It is well established that the health of individuals is not influenced solely by access to
health care services, but by a variety of variables (28) that include individual
characteristics (genetics, personnel behavior patterns), environmental characteristics
(workplace, school, home, pollution, water quality) and social characteristics of a society
(government policy, income equality and access to employment and education
opportunities). In addition research primarily conducted in England provides evidence
that a “social gradient” exists with relation to health. People of higher social standing
measured by level of income, education and type of employment live healthier and
longer lives than individuals that are less well-off (Black report, Acheson report,
Whitehall study, Kaplan and Lynch in Canada). Research on obesity supports these
findings. Individuals with low levels of education and income, low levels of activity, who
live in rural areas, are more likely to be either overweight or obese than their better-off,
more active urban counterparts. In addition education appears to be the most influential
variable after conducting statistical analyses (29).
Obesity and Health Services Utilization Patterns
Many studies demonstrate increased health services utilization by obese individuals. A
study published in the Canadian Medical Association Journal in 1999 by Trakas et. zl.
(30) using the National Population Health Survey (NPHS 1994), set out to determine:
the prevalence of obesity in Canadians; the associated co-morbidities and the patterns
of health system utilization by this population. The NPHS is a national survey
administered to approximately 17 000 Canadians (random sample) aged 20-64 years.
Information was collected on body-mass-index; health status scores and self-esteem
Healthcare utilization admissions and drug usage were determined for obese and none-
obese individuals through both face-to-face and telephone interviews. Several findings
are of interest. The obese population (as classified by a BMI > 30kg/m2) demonstrated:
higher rates of GP visits and visits to mental health professionals and higher rates of
disability days. The obese population was more likely to be taking heart medication,
11
antihypertensive, diuretics, oral diabetes pills, antidepressants, diet pills, antibiotics,
stomach remedies and pain relievers for arthritis and back pain. Similarly, a number of
studies conducted in England, Australia and the United States report increased utilization
of health services by this population (31-34).
Epidemiology of obesity in NL
Newfoundland and Labrador has the highest prevalence of overweight and obese adults
in Canada. According to the 1994/1995 NPHS and the 2000/2001 CCHS, the overall
prevalence of adult obesity in NL increased from 18% to 21% of the total population
(Figure 6) compared to the national average increase in the total population of 13% to
15%. In 2003 the prevalence of overweight in Newfoundland and Labrador was 39%
versus 33% in Canada. In this province two of every ten people are obese, four of ten
are overweight and four of ten are considered to have a normal weight. Although this
prevalence is comparable with the other Atlantic Provinces, Newfoundland and Labrador
has the highest prevalence of obesity across the provinces after the Northwest
Territories and Nunavut. The increasing prevalence of obesity in Newfoundland and
Labrador is a major cause for concern. It is fundamental that we understand the true
burden of obesity, in terms of individual health, its impact on society, and its impact on
the health system in order to efficiently allocate scarce resources towards the prevention
or overweight and obesity in the population.
12
% Obese in Canada/Atlantic Canada
0
5
10
15
20
25
94/95 96/97 98/99 00/01 2002/2003
year
% obese
Canada
NL
PEI
NS
NB
% Overweight in Canada/Atlantic Canada
20
25
30
35
40
45
94/95 96/97 98/99 00/01 2002/2003
year
%
Canada
NL
PEI
NS
NB
Fi
g
ure 6
Fi
g
ure 7
13
% Normal weight Canada/Atlantic Canada
0
10
20
30
40
50
60
94/95 96/97 98/99 00/01 2002/2003
time
%
Canada
NL
PEI
NS
NB
The results of a study published in the Canadian Medical Association Journal (26 by
Canning et al. reported that 25% of children (aged 3.5-5 years) who participated in their
Preschool Health Check in Newfoundland and Labrador were already either overweight
or obese. These results provide a valid report of body mass index for children in NL as
they are based on real measurements and not self-reported survey data. Canning et al.
compared the 1997 measurement results to measurements taken of children attending
their Preschool Health Check in 1984. Over this time period (13 years), the number of
overweight children increased by 28%, and the number of obese children increased by
175% (Table 1).
Prevalence of obesity and overweight in NL children*
P.Canning M.Courage L.Frizell
Memorial University
165%8.218.53.114.0Girls
178%7.816.82.813.7Boys
175%8.017.72.913.8All
obeseoverweightobeseoverweight
Increase
%
1997 %*
(4171)
1984 %
(781)
*CMAJ, Aug 2004
Fi
g
ure 8
Table 1
14
Obesity in the NL Health Boards
According to the Canadian Community Health Survey in 2003, the prevalence of
overweight and obesity in adults aged between 18 to 64 years across health regions in
NL shows large variation. Health and Community Services Eastern region and Grenfell
Regional Health Services have the highest prevalence of overweight at 42.65% and
47.4%, respectively. The Eastern health board and the Health Labrador Corporation
have the highest rates of obesity at 23.4% and 26.2 %, respectively (Table 2).
NL HCSSJ* HCSE* HCSC* HCSW* GRHS** HLC**
overweight 38.6 37.1 42.6 37.5 36.2 47.4 39.1
obese 20.1 17.5 23.4 21.2 18.3 21.9 26.2
*HCSSJ-Health & Community Services St. John’s, Eastern, Central, Western, **Grenfell Regional
Health Services, **Health Labrador Corporation
Note: these rates are for the original Health & Community Services Boards, not the newly formed
Regional Integrated Health Boards as Statistics Canada has not updated its geographical regions.
Peer group analysis
Although the prevalence of obesity doubled in most western countries over the last 25
years, large variations exist between countries, within a country and within a particular
geographic area. Within Canada the prevalence of obesity increases from East to West.
Newfoundland and Labrador has the highest prevalence of obesity after the Territories.
Little research has been conducted to investigate explanations for these differences;
however factors such as income, education and employment are associated with the
prevalence of obesity through an inverse relationship (i.e. the higher the level of
education the less likely one is to be obese). It is suggested that social determinants
may explain some of the variation. However, using a peer group analysis these
associations become less straightforward. Statistics Canada compares similar
geographic regions across Canada. Similar is defined by using several variables such
as: population change over time; demographic structure; social status of the
individuals; economic status; ethnicity; housing; urbanization; income equality and
Table 2
Prevalence of overweight and obesity in the NL community boards
15
labour market conditions. When these regions are compared the relationship between
social status and obesity is reduced. Figure 9 illustrates the difference in the prevalence
of obesity across “similar” regions in Canada. The prevalence varies from 17% for a
region in Quebec, to 24% for the Central region of Newfoundland. More research is
needed to understand these variations so that effective programs and policy can be
implemented.
Is obesity a preventable condition?
A report by the Canadian Institutes of Health Research in 2003 “Addressing Childhood
Obesity: The Evidence for Action” compiled and critically appraised systematic reviews
on the prevention and treatment of obesity. It concluded that current evidence is
insufficient to support health prevention or promotion programs focused on promoting
people to eat less and take more exercise. Other studies aimed at preventing obesity in
school-age children concluded there is some doubt as to whether obesity is preventable
in school-age children using currently available intervention strategies (23;27;37). The
Figure 9
Prevalence of obesit
y
in
“
similar
”
re
g
ions across Canada 2003
16
few successful interventions were resource intensive and complex and more likely to
come from the United States and therefore limited in generalizability to the Canadian
setting. Although there appears to have been little success in
targeted interventions
to
promote increased activity and health eating a study by the Canadian Institute of Health
Information (CIHI) published in 2005 demonstrated that schools in Nova Scotia
participating in coordinated programs that promoted healthy eating and increased
physical activity had significantly lower rates of overweight and obesity than schools that
had no such identified program (35). These results provide some evidence that an
overall policy approach may be more may be more successful than targeted
interventions.
Local Prevention Efforts
In NL there is a pilot study underway in Central Newfoundland called “Active Schools”
based on a successful program introduced throughout the Thames Valley School Board
in Ontario in 1998. The program is a concerted attempt to implement Health Canada’s
Physical Activity Guide for Youth and Children which recommends 30 minutes of physical
activity per day. Participating schools aim for 180 minutes of physical activity in a six day
cycle. Most schools have two 40 minute gym classes a cycle which leaves 100 minutes
to be divided between the remaining four days. Therefore an extra 20 minutes of
activity is included in each regular school day outside regular a gym classes. Initial
feedback has been positive from both teachers and students. As well as increased levels
of physical activity in the schools, there has been a reduction in problem behaviors in
the classroom as well as improved academic performance.
In Newfoundland the “Active Schools” initiative is a collaborative partnership between
representatives from health and education in an effort to increase the health of students
in the schools of Lewisporte/Gander District. A group of stakeholders made up of local
physicians, dieticians, fitness leaders, and health promotion professionals formed the
Active Living Committee in Gander in the fall of 2003. Their mandate was to raise the
community’s awareness of physical inactivity as a serious health risk. A subcommittee
initiated contact with the local school board to discuss concerns and to advocate for
policy change towards adopting the “Active Schools” model in some of its elementary
17
schools for the 2004 school year as a pilot project. A presentation was made to the Safe
and Healthy Schools Committee which led to a second presentation at a retreat of all the
school principals and administrators from the Lewisporte Gander School District. This
resulted in four school principals expressing a desire to pilot the “Active Schools” Model
in their schools beginning in September 2004. Contact was made with a principal in the
Thames Valley School Board in Ontario who gives presentations to health care
professionals interested in the “Active Schools” Program. A number of community
partners expressed their support of the project including Health and Community
Services-Central, Central East Health Care Institutions Board, Lewisporte/Gander School
District, Nine Wing Gander, Canadian Diabetes Association, Coalition for Active Living,
Newfoundland Medical Association, College of Family Physicians and the Canadian
Pediatric Society. The pilot project is being evaluated by a group of researchers in the
Department of Kinesiology and Human Kinetics.
What is the medical treatment for obesity?
Few treatment strategies for obesity have been found to work. The interventions
supported by research are surgery for the morbidly obese, drugs and multi-component
weight loss programs consisting of diet, exercise and behavioral therapy (36;37;38).
These studies were conducted with adults in clinical settings and have resulted in
modest weight loss in the long-term (39).
There is some evidence to support the treatment for childhood obesity through
specialty clinics (40). This “treatment” is limited to children defined as “clinically obese”
(based on specific medical criteria) and children where the affected child and family
appear willing to make the necessary lifestyle changes to promote healthy active living.
In this instance the focus of treatment is child-centered and family-based. The objective
of these clinics is to: manage and resolve co-morbidities and aim for behavioral change
(not weight loss); encourage healthier eating, increased activity and a reduction of
television watching. A crucial element in obtaining behavior change is to involve the
family in the monitoring of eating and activity, and in making the necessary lifestyle
changes.
18
Local Treatment Options
In September, 2005 the Healthcare Corporation of St. John’s opened an “Obesity
Lifestyle Clinic” at the Janeway Children’s Hospital. This Clinic is resourced by an
interdisciplinary team and includes: a Pediatric Endocrinologist; a Pediatrician in
Adolescent Medicine; a Nurse Practitioner; a Dietician; a Physiotherapist; a Recreation
Therapist; a Social worker and a Clinical Psychologist. The Clinic is an assessment and
intervention health service for children and adolescents (12-17 yrs) with obesity, as well
as their families. The purpose is to promote lifestyle changes to improve healthy active
living. Patients are identified by their family doctors or pediatricians and referred to the
Lifestyle Clinic for evaluation, assessment and treatment. Referred patients are sent a
package of information to be completed and returned before an initial consultation
appointment is confirmed with the Lifestyle team. The package of information includes:
• surveys on dietary intake
• surveys on physical activity
• surveys on self esteem
• a letter and lab slip advising of specific lab tests that must be conducted before
the first consultation.
The patient is selected for the clinic based on the information returned in the startup
package and specific criteria including, but not limited to, the client being between the
ages of 12 and 17 with a body mass index in the 95th percentile (classified as obese),
and commitment from a parent or guardian to attend all Clinic meetings and any further
treatment. The development of the clinic has arisen from an increasing number of obese
children being seen in regular pediatric clinics, and a feeling that the “standard of care”
(referral to a dietician for nutrition counseling) is not adequate for treating this complex
health problem. As of June 2005, the clinic had been running for nine months.
According to Dr. Tracey Bridger:
“The Lifestyle Clinic has been up and running since September 2004 and is held
every Thursday afternoon. We receive referrals mostly from general pediatricians,
sub-specialists, and family doctors. Each patient is seen by a team of health
professionals with the Lifestyle Clinic: MD/Nurse practitioner, dietitian,
physiotherapist, psychologist/Social worker. Initially, we opened the clinic to youth
aged 12-18y. However, we receive numerous consults for children <12y. These
19
children are usually then seen in the endocrine clinic by Dr. Bridger, the
endocrinologist with the Lifestyle Team. There are plans in the future to open the
clinic up to all children/youth. The biggest obstacle is one of manpower. For this
program to work properly, each child/youth and their family must be seen
frequently in order to learn about healthy eating, active living, and how to improve
motivation/behavioral changes. This is very labor intensive. So far, the clinic seems
to be running successfully, though we have not yet completed our formal
assessment. We are getting numerous referrals and have a good patient load. As
with any new program, we’ve been trying to improve things as we go and are
currently embarking on an updated treatment program, which we plan to offer to
both children and youth. Of course, the resource issue remains our biggest
challenge. The Lifestyle Clinic is a worthwhile and important program; we hope that
with the proper resources we will be able to bring it to the next level so that many
more children/youth and their families throughout the province can benefit”.
Conclusions and Discussion
The rising prevalence of obesity is a global concern for all societies. In Canada, the
Atlantic region, particularly Newfoundland and Labrador is of most concern with higher
than average overweight and obesity rates when compared to the rest of the country.
Both childhood and adult obesity are associated with adverse health consequences
which can both decrease quality of life and life expectancy. The cost of adult obesity has
been estimated to be $1.8 billion in Canada and several studies have shown increased
utilization of health care resources (hospital and physician visits, drug utilization) by
obese populations. The health services utilization patterns and the cost of obesity in
Newfoundland and Labrador are presently being studied by a team of researchers from
Memorial University and the NL Centre for Health Information.
The causes of this “epidemic” are multi-factorial. The relatively short time-period
associated with the increase in obesity provides evidence for environmental change
versus change in the genetics of the population. Although there is no question that
genetics plays an important role in predisposing certain individuals to gain excess
weight, and allows our bodies to stores excess energy , researchers agree that the
changing environment (> past 25 years) has more of an influence on any individual’s
20
consumption and activity patterns than our genetic profiles. Due to the ineffectiveness
of the clinical treatment and the “tracking” of obesity, it is important that the focus of
research and policy be in the areas of prevention and health promotion. A study
published recently by the Canadian Population Health Initiative (36) entitled “Overweight
and Obesity in Canada, a Population Health Perspective” reviewed extensively the
research published on successful population health interventions. It concluded that
interventions at the population level can only be successful if:
there is an integrated, multidisciplinary coordinated approach to policy by the
many stakeholders and policy actors (government, health professionals, national
organizations, community groups, public)
it includes a range of complementary actions (Healthy School policies, work-site
exercise facilities, food manufacturing buy-in) aimed at
individuals, groups, communities and institutions and public policy.
In addition the report suggested that for obesity prevention efforts to be both successful
and sustainable it is mandatory to have “political buy-in” or political will. To implement
population based interventions, dedicated resources (time, money, staff) must be
committed to social change. New programs must be integrated into existing structure
and programs to ensure long-term sustainability. Analysis of major public health
successes such as smoking, seatbelt legislation and education around HIV/AIDS
demonstrate that population health interventions can work. These evaluations should
be used to help guide prevention efforts and on-going health promotion in this area.
21
Bibliography
(1) The World Health Organization (2000). Obesity: Preventing and Managing the Global Epidemic.
Geneva, World Health Organization.
(2) Birmingham CL, Palepu A, Spinelli J, Anis AH. The cost of obesity in Canada. The Canadian Medical
Association Journal. 2000; 64(4): 483-488.
(3) Tsai WL, Yang CY, Lin SF, Fang FM (2004). Impact of obesity on medical problems and quality of life
in Taiwan. Am J Epidemiol. 2004; 15:160(6):557-65.
(4) Tremblay M S. Secular trends in the body mass index of Canadian children. The Canadian Medical
Association Journal. 2000;163(11):1429-1433.
(5) Willms JD, Tremblay MS, Katzmarzyk PT. Geographic and demographic Variation in the Prevalence of
Overweight Canadian Children. Obesity Research. 2003; 11:668-673.
(6) Calle EE, Body Mass Index and Mortality in a prospective cohort or U.S. adults. The New England
Journal of Medicine. 1999;341:1097-1105.
(7) World Health Organization. Obesity Report 2000.
(8) Hofmanns MD, Kromhout D, de Lezenne-Coulander C. The impact of body mass index of 78,612 18
year old Dutch men on 32 year mortality from all causes. Journal of Clinical Epidemiology. 1988;41:
749-756.
(9) Eckel, R. Obesity and heart disease: a statement for healthcare professionals from the Nutrition
Committee. Circulation. 1997; 96: 3248-3250.
(10) Pietrobelli A, Steinbeck KS. Pediatric obesity: what do we know and are we doing the right thing?
International Journal of Obesity. 2004; 28(1): 2-3.
(11) Willett WC. Weight, weight change, and coronary heart disease in women. Risk within the normal
weight range. JAMA. 1995; 273: 461-465.
(12) Chang JM, Rimm EB, Colditz GA, Stampfer MJ, Willett WC. Obesity, fat distribution, and weight gain as
risk factors for clinical diabetes in men. Diabetes Care. 1994; 17: 961-99.
(13) Strauss RS. Childhood obesity and self esteem. Pediatrics.2000; 105: 15.
(14) Erickson SJ, Robinson TN, Haydel KF, Killen JD. Are overweight children unhappy? Body mass index,
depressive symptoms, and overweight concerns in elementary school children. Arch Pediatr Adolesc
Med. 2000;154: 931-935.
(15) Freedman DS, Khan LK, Dietz WH, Srinivasan SR, Berenson GS. Relationship of childhood obesity to
coronary heart disease risk factors in adulthood: The Bogalusa Heart Study. Pediatric.2001; 108:712-
718.
(16) Chu NF, Wang DJ, Shieh SM, Rimm EB. Plasma leptin concentrations and obesity in relation to insulin
resistance syndrome components among school children in Taiwan – The Taipei Children Heart Study.
International Journal of Obesity.2000; 25:1265-1271.
(17) Reilley JJ, et al. Health Consequences of Obesity. Arch Dis Child. 2003; 88:748-752.
(18) Figueroa-Munoz JJ, Chinn S, Rona RJ. Association between obesity and asthma in 4-11 year old
children in the UK. Thorax.2001;56: 133-137.
22
(19) Chinn S, Rona RJ . Can the increase in body mass index explain the rising trend in asthma in children?
Thorax.2001; 56(11): 845-850.
(20) Dwyer O. First case of type 2 diabetes found in white UK teenagers. The British Medical Journal.
2002; 324(7336): 506.
(21) Douketis JD, Feightner J.W, Attia J, Feldman WF. Periodic health examination, 1999 update 1.
Detection, prevention and treatment of obesity. The Canadian Medical Association
Journal.1999;160(4): 513-525.
(22) Sargent JD, Blanchflower DG. Obesity and stature in adolescence and earnings in young adulthood.
Analysis of a British birth cohort. Arch Pediatr Adolesc med, 1994; 148: 681-687.
(23) Gortmaker SL, Peterson K, Wiecha J, et al. Reducing obesity via a school-based interdisciplinary
intervention among youth: Planet Health. Arch Pediatr Adolesc Med. 1999; 153(4):409-18.
(24) Freedman DS, Khan LK Dietz WH Srinivasan SR Berenson GS. Relationship of childhood obesity to
coronary heart disease risk factors in adulthood: the Bogalusa Heart Study. Pediatrics.2001;108: 712-
718.
(25) Laitinen J,Power C, Järvelin M. Family social class, maternal body mass index, childhood body mass
index, and age at menarche as predictors of adult obesity, American Journal of Clinical Nutrition.
2001;74:287-294.
(26) Canning PM, Courage ML, Frizzell LM. Prevalence of overweight and obesity in a provincial population
of Canadian preschool children. The Canadian Medial Association Journal.2004;171(3): 240-242.
(27) Addressing Childhood Obesity: The Evidence for Action. The Canadian Institutes for Health Research
2003.
(28) Evans R, Barer M, Marmor R. Why are some people healthy and others not? The determinants of
population.
(29) Improving the Health of Canadians (2004) A Canadian Population Health Initiative www.cihi.ca
(30) Trakas K, Lawrence K, Shear N. Utilization of health care resources by obese Canadians. The Canadian
Medical Association Journal.1999:160(10):1457-1462.
(31) Folasade AP. Increase in Obesity and Health-Care Use, from Health Survey for England, Ages 50-69,
1998. Obesity Surgery:2004;14:1258-1262.
(32) Redipath D, Crawford D, Tilgner L, Gibbons C. Relationship between body mass index and the use of
Healthcare Services in Australia. Obesity Research. 2002:10(6):526-531.
(33) Tatiana A, Strum R, Ringel J. Moderate and Severe Obesity have large differences in health care costs.
Obesity Research 2004:12(12):1936-1943.
(34) Bertakis K, Rahman A. Obesity and the use of Health Care Serivces. Obesity Research 2005:13(2):372-
379.
(35) Veugelers P, Fitzgerald A. Effectiveness of School Programs in Preventing Childhood obesity: A
multilevel comparison. American Journal of Public Health 2005:95(3):432-435.
(36) Overweight and obesity in Canada A population health perspective. Canadian Population Health
Initiative. 2004 Kim Raine. www.cihi.ca.
(37) Epstein LH, Paluch RA, Gordy CC, Dorn J. Decreasing sedentary behaviors in treating pediatric obesity.
Arch Pediatr Adolesc Med.2000;154: 220-226.
23
(38) Mellin LM, Slinkard LA, Irwin CE Jr.. Adolescent obesity intervention: validation of the SHAPEDOWN
program. Journal of American Diet Associatio.1987;87: 333-338.
(39) Mctigue KM, Harris R., Hemphill B, Lux L , Sutton S, Bunton AJ, Lohr KN. Screening and interventions
for obesity in adults: summary of the evidence for the US Preventive Services Task Force. Am Intern
Med.2003;139(11): 933-949.
(40) Barlow S, Dietz WH. Obesity evaluation and treatment: expert committee recommendations.
Pediatrics.1998;102(3): E29.