Y. Claire Wang

Health and economic burden of the projected obesity trends in the USA and the UK

Rising prevalence of obesity is a worldwide health concern because excess weight gain within populations forecasts an increased burden from several diseases, most notably cardiovascular diseases, diabetes, and cancers. In this report, we used a simulation model to project the probable health and economic consequences in the next two decades from a continued rise in obesity in two ageing populations--the USA and the UK. These trends project 65 million more obese adults in the USA and 11 million more obese adults in the UK by 2030, consequently accruing an additional 6-8·5 million cases of diabetes, 5·7-7·3 million cases of heart disease and stroke, 492,000-669,000 additional cases of cancer, and 26-55 million quality-adjusted life years forgone for USA and UK combined. The combined medical costs associated with treatment of these preventable diseases are estimated to increase by

Increasing Caloric Contribution From Sugar- Sweetened Beverages and 100% Fruit Juices Among US Children and Adolescents, 1988-2004

48-66 billion/year in the USA and by £1·9-2 billion/year in the UK by 2030. Hence, effective policies to promote healthier weight also have economic benefits.

Quantification of the effect of energy imbalance on bodyweight

OBJECTIVE. We sought to document increases in caloric contributions from sugar-sweetened beverages and 100% fruit juice among US youth during 1988–2004. PATIENTS AND METHODS. We analyzed 24-hour dietary recalls from children and adolescents (aged 2–19) in 2 nationally representative population surveys: National Health and Nutrition Examination Survey III (1988–1994, N = 9882) and National Health and Nutrition Examination Survey 1999–2004 (N = 10 962). We estimated trends in caloric contribution, type, and location of sugar-sweetened beverages and 100% fruit juice consumed. RESULTS. Per-capita daily caloric contribution from sugar-sweetened beverages and 100% fruit juice increased from 242 kcal/day (1 kcal = 4.2 kJ) in 1988–1994 to 270 kcal/day in 1999–2004; sugar-sweetened beverage intake increased from 204 to 224 kcal/day and 100% fruit juice increased from 38 to 48 kcal/day. The largest increases occurred among children aged 6 to 11 years (∼20% increase). There was no change in per-capita consumption among white adolescents but significant increases among black and Mexican American youths. On average, respondents aged 2 to 5, 6 to 11, and 12 to 19 years who had sugar-sweetened beverages on the surveyed day in 1999–2004 consumed 176, 229, and 356 kcal/day, respectively. Soda contributed ∼67% of all sugar-sweetened beverage calories among the adolescents, whereas fruit drinks provided more than half of the sugar-sweetened beverage calories consumed by preschool-aged children. Fruit juice drinkers consumed, on average, 148 (ages 2–5), 136 (ages 6–11), and 184 (ages 12–19) kcal/day. On a typical weekday, 55% to 70% of all sugar-sweetened beverage calories were consumed in the home environment, and 7% to 15% occurred in schools. CONCLUSIONS. Children and adolescents today derive 10% to 15% of total calories from sugar-sweetened beverages and 100% fruit juice. Our analysis indicates increasing consumption in all ages. Schools are a limited source for sugar-sweetened beverages, suggesting that initiatives to restrict sugar-sweetened beverage sales in schools may have an only marginal impact on overall consumption. Pediatricians’ awareness of these trends is critical for helping children and parents target suboptimal dietary patterns that may contribute to excess calories and obesity.

Increasing consumption of sugar-sweetened beverages among US adults: 1988–1994 to 1999—2004

Obesity interventions can result in weight loss, but accurate prediction of the bodyweight time course requires properly accounting for dynamic energy imbalances. In this report, we describe a mathematical modelling approach to adult human metabolism that simulates energy expenditure adaptations during weight loss. We also present a web-based simulator for prediction of weight change dynamics. We show that the bodyweight response to a change of energy intake is slow, with half times of about 1 year. Furthermore, adults with greater adiposity have a larger expected weight loss for the same change of energy intake, and to reach their steady-state weight will take longer than it would for those with less initial body fat. Using a population-averaged model, we calculated the energy-balance dynamics corresponding to the development of the US adult obesity epidemic. A small persistent average daily energy imbalance gap between intake and expenditure of about 30 kJ per day underlies the observed average weight gain. However, energy intake must have risen to keep pace with increased expenditure associated with increased weight. The average increase of energy intake needed to sustain the increased weight (the maintenance energy gap) has amounted to about 0·9 MJ per day and quantifies the public health challenge to reverse the obesity epidemic.

Estimating the Energy Gap Among US Children: A Counterfactual Approach

BACKGROUND Consumption of sugar-sweetened beverages (SSBs) has been linked to obesity and type 2 diabetes. OBJECTIVE We examined national trends in SSB consumption among US adults by sociodemographic characteristics, body weight status, and weight-loss intention. DESIGN We analyzed 24-h dietary recall data to estimate beverage consumption among adults (aged > or = 20 y) obtained from the third National Health and Nutrition Examination Survey (NHANES III, 1988-1994; n = 15,979) and NHANES 1999-2004 (n = 13,431). RESULTS From 1988-1994 to 1999-2004 on the survey day, the percentage of adult SSB drinkers increased from 58% to 63% (P < 0.001), per capita consumption of SSB increased by 46 kcal/d (P = 0.001), and daily SSB consumption among drinkers increased by 6 oz (P < 0.001). In both survey periods, per capita SSB consumption was highest among young adults (231-289 kcal/d) and lowest among the elderly (68-83 kcal/d). Young blacks had the highest percentage of SSB drinkers and the highest per capita consumption compared with white and Mexican American adults (P < 0.05). Overweight-obese adults with weight-loss intention (compared with those without) were significantly less likely to drink SSB, but they still consumed a considerable amount in 1999-2004 (278 kcal/d). Among young adults, 20% of SSB calories were consumed at work. CONCLUSIONS Over the past decade, US adult SSB consumption has increased. SSB comprises a considerable source of total daily intake and is the largest source of beverage calories. SSB consumption is highest among subgroups also at greatest risk of obesity and type 2 diabetes.

Future Cardiovascular Disease in China Markov Model and Risk Factor Scenario Projections From the Coronary Heart Disease Policy Model–China

OBJECTIVE. Our goal was to quantify the magnitude of energy imbalance responsible for the increase in body weight among US children during the periods 1988–1994 and 1999–2002. METHODS. We adopted a counterfactual approach to estimate weight gains in excess of normal growth and the implicit “energy gap”—the daily imbalance between energy intake and expenditure. On the basis of Centers for Disease Control and Prevention growth charts, we constructed weight, height, and BMI percentile distributions for cohorts 2 to 4 and 5 to 7 years of age in the 1988–1994 National Health and Nutrition Examination Survey (N = 5000). Under the counterfactual “normal-growth-only” scenario, we assumed that these percentile distributions remained the same as the cohort aged 10 years. Under this assumption, we projected the weight and height distributions for this cohort at 12 to 14 and 15 to 17 years of age on the basis of their baseline weight-for-age and stature-for-age percentiles. We compared these distributions with those for corresponding age groups in the 1999–2002 National Health and Nutrition Examination Survey (N = 3091) ∼10 years after the 1988–1994 National Health and Nutrition Examination Survey. We calculated differences between the counterfactual and observed weight distributions and translated this difference into the estimated average energy gap, adjusting for increased total energy expenditure attributable to weight gain. In addition, we estimated the average excess weight accumulated among overweight adolescents in the 1999–2002 National Health and Nutrition Examination Survey, validating our counterfactual assumptions by analyzing longitudinal data from the National Longitudinal Survey of Youth and Bogalusa Heart Study. RESULTS. Compared with the counterfactual scenario, boys and girls who were aged 2 to 7 in the 1988–1994 National Health and Nutrition Examination Survey gained, on average, an excess of 0.43 kg/year over the 10-year period. Assuming that 3500 kcal leads to an average of 1-lb weight gain as fat, our results suggest that a reduction in the energy gap of 110–165 kcal/day could have prevented this increase. Among overweight adolescents aged 12 to 17 in 1999–2002, results indicate an average energy imbalance ranging from 678 to 1017 kcal/day because of an excess of 26.5 kg accumulated over 10 years. CONCLUSIONS. Quantifying the energy imbalance responsible for recent changes in weight distribution among children can provide salient targets for population intervention. Consistent behavioral changes averaging 110 to 165 kcal/day may be sufficient to counterbalance the energy gap. Changes in excess dietary intake (eg, eliminating one sugar-sweetened beverage at 150 kcal per can) may be easier to attain than increases in physical activity levels (eg, a 30-kg boy replacing sitting for 1.9 hours with 1.9 hours walking for an extra 150 kcal). Youth at higher levels of weight gain will likely need changes in multiple behaviors and environments to close the energy gap.

Impact of Change in Sweetened Caloric Beverage Consumption on Energy Intake Among Children and Adolescents

Background—The relative effects of individual and combined risk factor trends on future cardiovascular disease in China have not been quantified in detail. Methods and Results—Future risk factor trends in China were projected based on prior trends. Cardiovascular disease (coronary heart disease and stroke) in adults ages 35 to 84 years was projected from 2010 to 2030 using the Coronary Heart Disease Policy Model–China, a Markov computer simulation model. With risk factor levels held constant, projected annual cardiovascular events increased by >50% between 2010 and 2030 based on population aging and growth alone. Projected trends in blood pressure, total cholesterol, diabetes (increases), and active smoking (decline) would increase annual cardiovascular disease events by an additional 23%, an increase of approximately 21.3 million cardiovascular events and 7.7 million cardiovascular deaths over 2010 to 2030. Aggressively reducing active smoking in Chinese men to 20% prevalence in 2020 and 10% prevalence in 2030 or reducing mean systolic blood pressure by 3.8 mm Hg in men and women would counteract adverse trends in other risk factors by preventing cardiovascular events and 2.9 to 5.7 million total deaths over 2 decades. Conclusions—Aging and population growth will increase cardiovascular disease by more than a half over the coming 20 years, and projected unfavorable trends in blood pressure, total cholesterol, diabetes, and body mass index may accelerate the epidemic. National policy aimed at controlling blood pressure, smoking, and other risk factors would counteract the expected future cardiovascular disease epidemic in China.

Trends and racial/ethnic disparities in severe obesity among US children and adolescents, 1976–2006

OBJECTIVE To estimate the net caloric impact from replacing sugar-sweetened beverages (SSBs) with alternatives in children and adolescents in naturalistic settings. DESIGN Secondary analysis based on nationally representative cross-sectional study. SETTING Fixed-effect regression analysis of 2 nonconsecutive 24-hour dietary recalls from the 2003-2004 National Health and Nutrition Examination Survey data. PARTICIPANTS Children and adolescents 2 to 19 years of age (N = 3098). MAIN EXPOSURES Within-person beverage consumption between 2 surveyed days. MAIN OUTCOME MEASURES The association between changes in the consumption of SSBs and other beverages and changes in total energy intake (TEI) of the same individual. RESULTS Each additional serving (8 oz) of SSB corresponded to a net increase of 106 kcal/d (P < .001; 95% confidence interval [CI], 91 to 121 kcal/d), holding other beverages constant. Increases were also seen (all P < .001) for each additional serving of whole milk (169 kcal/d; 95% CI, 143 to 195 kcal/d), reduced-fat milk (145 kcal/d; 95% CI, 118 to 171 kcal/d), and 100% juice (123 kcal/d; 95% CI, 90 to 157 kcal/d). No net increases in TEI were seen for water (8 kcal/d; P = .27; 95% CI, -6 to 22 kcal/d) or diet drinks (47 kcal/d; P = .20; 95% CI, -23 to 117 kcal/d). Substituting SSBs with water was associated with a significant decrease in TEI, controlling for intake of other beverages, total beverage and nonbeverages, and fast-food and weekend effects. Each 1% of beverage replacement was associated with 6.6-kcal lower TEI, a reduction not negated by compensatory increases in other food or beverages. We estimate that replacing all SSBs with water could result in an average reduction of 235 kcal/d. CONCLUSION Replacing SSB intake with water is associated with reductions in total calories for all groups studied.

Forecasting the obesity epidemic in the aging U.S. population.

Abstract Introduction. This study aims to describe the trends and racial/ethnic differences in prevalence of severe obesity among US children. Methods. We examined height and weight measurements from US children and adolescents aged 2 to 19 years using three National Health and Nutrition Examination Surveys (NHANES II: 1976-1980, N = 7 201, NHANES III: 1988-1994, N = 10 600, and NHANES 1999-2006, N = 15 980). We estimated the prevalence of severe obesity, defined as having a body mass index (BMI) above 35 kg/m(2) or 120% of the age- and sex-specific 95(th) percentile on the CDC reference standards, stratified by sex and age groups (aged 2-5 years, 6-11 years, and 12-19 years). We compared prevalence estimates among non-Hispanic white, non-Hispanic black, and Hispanic children. Results. The age-standardized prevalence of severe obesity increased from 1.1%/1.3% (boys/girls) in NHANES II, to 2.9%/3.1% in NHANES III and 5.1%/4.7% in NHANES 1999-2006 (p-values for trend <0.001). We observed some differences in prevalence by race/ethnicity. Hispanic boys 6-11 years of age (9.0%, 95% CI: [6.4, 11.5]) and non-Hispanic black girls 12-19 years of age (12.6%, 95% CI: [10.6, 14.6]) had the highest prevalence of severe obesity in the most recent NHANES data. On average, obese youth were 9.7 kg (95% CI: [9.2, 10.2]) above the obesity standard, and severely obese youth were 21.3 kg (95% CI: [20.5, 22.3]) above. Conclusions. The prevalence of severe obesity among US youth is increasing, especially among Hispanic boys and non-Hispanic black girls. Our findings suggest that the degree of pediatric obesity is substantial and will likely have profound impact on adult morbid obesity and other morbidities.

A Penny-Per-Ounce Tax On Sugar-Sweetened Beverages Would Cut Health And Cost Burdens Of Diabetes

Objective: The objective was to forecast BMI distribution in the U.S. population along with demographic changes based on past race‐, sex‐, and birth cohort‐specific secular trends.