In Focus
Tackling obesity in cities A London local authority is considering reducing benefits for residents with obesity who won’t follow exercise plans. Tony Kirby looks at methods employed across cities worldwide to battle the bulge. from the London 2012 Olympic Games would be a leaner, fitter London, and I want us to work swiftly towards the elimination of childhood obesity”, says Johnson. But he may be facing an uphill task, since almost two-thirds of the UK population does not meet minimum guidelines for physical activity, according to a recent Lancet Series. Argentina, Brazil, the USA, Italy, South Africa, Spain, and Portugal are among the other worst offenders in terms of levels of physical inactivity. In New York City, more than 5000 deaths per year are caused by obesity and overweight, and these conditions cost the city US$4 billion in direct medical costs alone. Regulation of trans-fat levels in restaurants and takeaways in 2007 attempted to eliminate these fats, which contain substantial calories but have no nutritional value. The city’s food establishments have largely followed the new rules. One study on fast-food purchases in New York City analysed lunchtime receipts from 168 locations of 11 fast-food chains and matched to available nutrition information in spring 2007 and 2009 (before and after regulation). It showed that the average trans-fat per purchase decreased by 2·4 g, with only a small increase in saturated fat of 0·5 g. Importantly, restaurant patrons from neighbourhoods of high and low poverty seemed to benefit equally in terms of reduced intake of trans-fats. The city was also the first in the USA to compel restaurants to publish calorie information on menus, crucial since on average New Yorkers get a third or more of their calories away from home. City officials have also implemented measures to increase access to affordable fresh fruit, vegetables, and other healthy foods,
www.thelancet.com/diabetes-endocrinology August 2013
and, in March 2013, will implement another pioneering initiative: portion size of sugary beverages served at food service establishments will be limited to 16 ounces (a bit less than half a litre). This will apply to restaurants, movie theatres, arenas, and even mobile food carts, but not to supermarkets or general stores. “We hope that this rule will help reacquaint New Yorkers with more human-sized portions”, says a spokeswoman for New York City’s Health Commissioner Thomas Farley. “Portion sizes of sugary drinks have grown, and studies show people consume more when given larger portions, often without even realising it. We hope this rule will decrease the consumption of sugary drinks, which have been linked to obesity and diabetes.” Middle-income countries also show examples of innovation to tackle obesity and promote physical activity within their populations. Bogotá, the capital city of Colombia, has transformed its urban environment to reduce car dependency and promote more physical activity. Since the 1970s, the city has benefited from the Ciclovía Recreativa, whereby about 100 km of streets are closed to traffic on Sundays and public holidays,
Published Online January 2013 For the report A Dose of Localism: The Role of Council in Public Health see http://www.lgiu.org. uk/a-dose-of-localism-the-roleof-councils-in-public-health/ For more on cycling in London see http://www.london.gov.uk/ priorities/transport/cyclingrevolution For The Lancet’s 2012 Series on physical activity see http:// www.thelancet.com/series/ physical-activity For the study on New York City and trans-fats see Ann Intern Med 2012; 157: 81–86. DOI:0.7326/00034819-157-2-201207170-00004 For more on New York’s efforts to tackle obesity see http:// www.nyc.gov/html/om/ pdf/2012/otf_report.pdf For more on New York’s efforts to reduce consumption of sugar-sweetened beverages see http://www.nyc.gov/html/doh/ html/cdp/cdp_pan_pop.shtml For more on CiclovÍas Recreativas see http://www. cicloviasrecreativas.org/en
Scott Warren/Aurora/SpecialistStock
2013 has begun as 2012 ended, with most developed countries in the grip of an obesity epidemic that is also transitioning to poorer nations. Some serious innovation is needed, and one local authority in London, UK, is doing just that. During the first week of 2013, Westminster City Council published its report A Dose of Localism: The Role of Council in Public Health, suggesting welfare benefits could be linked to behaviours that promote public health. The report states that ”local authorities should consider making provision for prescription of leisure activities in their service level agreements with health service providers”, and that ”where an exercise package is prescribed to a resident, housing and council tax benefit payments could be varied to reward or incentivise residents”. Westminster is just one small part of Greater London, which consists of 32 borough councils. On average, more than half of London adults and a third of children are obese or overweight. Among the concrete steps the city has already taken in terms of improving physical activity is the bicycle hiring system and cycle superhighways pioneered by the city’s Mayor Boris Johnson. The Mayor’s team is also working with police to reduce cycling casualties in traffic accidents, especially those involving lorries. The Mayor wants a four-fold increase in cycling by 2026 compared with 2001. Following the London 2012 Olympic Games, the Mayor’s Office, along with private donors, has distributed UK£40 million to various projects to promote physical activity. The projects cover facilities, training, and participation, with unusual programmes such as temporary swimming pools deployed in schools for 3-month periods to teach children to swim. “My perfect legacy
New York City has taken steps to reduce obesity
s1
In Focus
For more on The Lancet’s Healthy Cities see Lancet 2012; 379: 2079–108 For data for Australian obesity and activity levels see http:// www.abs.gov.au For the Swap It Don’t Stop It campaign see http://swapit.gov. au/ For the Change 4 Life campaign see http://www.nhs.uk/ change4life/
s2
promoting recreation activities in those areas. Between 600 000 and 1·4 million people use these streets to exercise every week, and 41% of adults participate for more than 3 h at a time. Moreover, research suggests that every $1 invested (both by the city and by individuals) leads to an estimated net annual saving in health costs of between $3·2 and $4·2 per person. “This increased activity is more common in young middleincome and high-income men than in other social groups. Since only 45% of Bogota’s adults are meeting guidelines for physical activity, it’s clear more needs to be done”, says Julio Dávila, a Colombian Academic from University College London (UCL) who coauthored the 2012 Lancet–UCL Commission Healthy Cities. Another initiative in Bogotá is Transmilenio, a mass-transit system launched in 2000 that uses Bus Rapid Transit technology, consisting of guided bus lanes that avoid the mass traffic jams that gridlock the city. A quarter of trips in the city are made using this network, and its introduction has not only reduced car use and commuting times, but also prompted users to walk further to fixed guided-lane bus stations than they would have previously, when buses stopped wherever requested. Less successful has been one of Bogotá’s other initiatives, the 334-km cycle path network (Ciclo-Rutas), established in 1998. Only 2% of daily journeys are made by bicycle in the city, and anecdotal evidence suggests that high death rates due to traffic accidents involving cyclists, fear of crime, and lack of secure bicycle parking are behind poor use of the network. But Dávila points out that “when you take account of Bogotá’s social problems, including the wide inequalities and woefully inadequate finances, most regard these efforts to improve physical activity and reduce obesity as successful”. Australia is also battling an obesity epidemic, with the country being fifth behind the USA, Mexico, New Zealand,
and the UK in terms of obesity rates. The epidemic costs the nation AU$50 billion every year. Data from Australia show that, after adjusting for age, adults living in the most disadvantaged areas had the highest prevalence of overweight and obesity (66%), whereas those living in areas of least disadvantage had the lowest prevalence (55%). Obesity (rather than overweight) shows a particular bias towards poorer areas—obesity rates in both men and women that are double those in the most affluent areas. Thus it could be said that it is pockets within cities, not entire cities, that are facing obesity epidemics. Furthermore, Sydney, which hosted the 2000 Olympic Games, does not have the lowest obesity or highest physical activity rates. These accolades are held by Perth, WA, and Canberra, ACT.
“...it is pockets within cities, not entire cities, that are facing obesity epidemics.” “This mostly reflects the higher levels of affluence in those cities and the better infrastructure for active transport, such as Canberra’s bicycle network”, says Adrian Bauman, an expert on physical activity from the University of Sydney. He decries that “No cities or state level jurisdictions in Australia are really tackling nutrition policy definitively”, and blames the many vested interests in the food industry. He says Australia is making genuine efforts nationally to target obesity through the running campaigns of the Federal Government’s Australian National Preventive Health Agency (ANPHA). One such campaign was Swap It Don’t Stop It , which ran from 2010 until 2012, similar in its nudge approach to small behaviour change to the Change 4 Life campaign recently launched by the UK Government, which has come in for heavy criticism because of its close working connection with the food industry.
“We have created communities and cities that are dominated by cars. We need to change this situation and design communities that promote walking and cycling”, says Fiona Bull, from the University of Western Australia, who gave a special presentation on physical activity at the World Economic Forum meeting in Davos-Klosters, Switzerland in January, 2013. But she is optimistic about the future. Bull points to community work being undertaken in both the UK and Australia to target food-related planning approvals such as new takeaways in a given area. And, as in New York City, voices in these countries are getting louder on sugarsweetened beverages. “The Heart Foundation and Cancer Council of Australia have come out very strongly in favour of banning, restricting, or taxing sugared and sweetened beverages. This is a policy initiative which is likely to influence total energy intake but is one which no state or national jurisdiction is willing to tackle at a policy level yet”, adds Bauman. Even Coca-Cola has entered the obesity debate, and is currently running a mass-media campaign that includes statements such as “beating obesity will take action by all of us, based on one simple, common-sense fact: all calories count, no matter where they come from”, followed by pointing out it offers a range of lowcalorie and zero calorie beverages. But the Center for Science in the Public Interest (CSPI, an American advocacy organisation targeting food, health, and alcohol policy) has been dismissive of Coca-Cola’s involvement. A CSPI spokesman said that “what the [sugar-sweetened beverage] industry is trying to do is forestall sensible policy approaches to reducing sugary drink consumption, including taxes, further exclusion from public facilities, and caps on serving sizes such as the measure proposed by New York’s Mayor Michael Bloomberg”.
Tony Kirby
www.thelancet.com/diabetes-endocrinology August 2013
Tackling obesity in cities A London local authority is considering reducing benefits for residents with obesity who won’t follow exercise plans. Tony Kirby looks at methods employed across cities worldwide to battle the bulge. from the London 2012 Olympic Games would be a leaner, fitter London, and I want us to work swiftly towards the elimination of childhood obesity”, says Johnson. But he may be facing an uphill task, since almost two-thirds of the UK population does not meet minimum guidelines for physical activity, according to a recent Lancet Series. Argentina, Brazil, the USA, Italy, South Africa, Spain, and Portugal are among the other worst offenders in terms of levels of physical inactivity. In New York City, more than 5000 deaths per year are caused by obesity and overweight, and these conditions cost the city US$4 billion in direct medical costs alone. Regulation of trans-fat levels in restaurants and takeaways in 2007 attempted to eliminate these fats, which contain substantial calories but have no nutritional value. The city’s food establishments have largely followed the new rules. One study on fast-food purchases in New York City analysed lunchtime receipts from 168 locations of 11 fast-food chains and matched to available nutrition information in spring 2007 and 2009 (before and after regulation). It showed that the average trans-fat per purchase decreased by 2·4 g, with only a small increase in saturated fat of 0·5 g. Importantly, restaurant patrons from neighbourhoods of high and low poverty seemed to benefit equally in terms of reduced intake of trans-fats. The city was also the first in the USA to compel restaurants to publish calorie information on menus, crucial since on average New Yorkers get a third or more of their calories away from home. City officials have also implemented measures to increase access to affordable fresh fruit, vegetables, and other healthy foods,
www.thelancet.com/diabetes-endocrinology August 2013
and, in March 2013, will implement another pioneering initiative: portion size of sugary beverages served at food service establishments will be limited to 16 ounces (a bit less than half a litre). This will apply to restaurants, movie theatres, arenas, and even mobile food carts, but not to supermarkets or general stores. “We hope that this rule will help reacquaint New Yorkers with more human-sized portions”, says a spokeswoman for New York City’s Health Commissioner Thomas Farley. “Portion sizes of sugary drinks have grown, and studies show people consume more when given larger portions, often without even realising it. We hope this rule will decrease the consumption of sugary drinks, which have been linked to obesity and diabetes.” Middle-income countries also show examples of innovation to tackle obesity and promote physical activity within their populations. Bogotá, the capital city of Colombia, has transformed its urban environment to reduce car dependency and promote more physical activity. Since the 1970s, the city has benefited from the Ciclovía Recreativa, whereby about 100 km of streets are closed to traffic on Sundays and public holidays,
Published Online January 2013 For the report A Dose of Localism: The Role of Council in Public Health see http://www.lgiu.org. uk/a-dose-of-localism-the-roleof-councils-in-public-health/ For more on cycling in London see http://www.london.gov.uk/ priorities/transport/cyclingrevolution For The Lancet’s 2012 Series on physical activity see http:// www.thelancet.com/series/ physical-activity For the study on New York City and trans-fats see Ann Intern Med 2012; 157: 81–86. DOI:0.7326/00034819-157-2-201207170-00004 For more on New York’s efforts to tackle obesity see http:// www.nyc.gov/html/om/ pdf/2012/otf_report.pdf For more on New York’s efforts to reduce consumption of sugar-sweetened beverages see http://www.nyc.gov/html/doh/ html/cdp/cdp_pan_pop.shtml For more on CiclovÍas Recreativas see http://www. cicloviasrecreativas.org/en
Scott Warren/Aurora/SpecialistStock
2013 has begun as 2012 ended, with most developed countries in the grip of an obesity epidemic that is also transitioning to poorer nations. Some serious innovation is needed, and one local authority in London, UK, is doing just that. During the first week of 2013, Westminster City Council published its report A Dose of Localism: The Role of Council in Public Health, suggesting welfare benefits could be linked to behaviours that promote public health. The report states that ”local authorities should consider making provision for prescription of leisure activities in their service level agreements with health service providers”, and that ”where an exercise package is prescribed to a resident, housing and council tax benefit payments could be varied to reward or incentivise residents”. Westminster is just one small part of Greater London, which consists of 32 borough councils. On average, more than half of London adults and a third of children are obese or overweight. Among the concrete steps the city has already taken in terms of improving physical activity is the bicycle hiring system and cycle superhighways pioneered by the city’s Mayor Boris Johnson. The Mayor’s team is also working with police to reduce cycling casualties in traffic accidents, especially those involving lorries. The Mayor wants a four-fold increase in cycling by 2026 compared with 2001. Following the London 2012 Olympic Games, the Mayor’s Office, along with private donors, has distributed UK£40 million to various projects to promote physical activity. The projects cover facilities, training, and participation, with unusual programmes such as temporary swimming pools deployed in schools for 3-month periods to teach children to swim. “My perfect legacy
New York City has taken steps to reduce obesity
s1
In Focus
For more on The Lancet’s Healthy Cities see Lancet 2012; 379: 2079–108 For data for Australian obesity and activity levels see http:// www.abs.gov.au For the Swap It Don’t Stop It campaign see http://swapit.gov. au/ For the Change 4 Life campaign see http://www.nhs.uk/ change4life/
s2
promoting recreation activities in those areas. Between 600 000 and 1·4 million people use these streets to exercise every week, and 41% of adults participate for more than 3 h at a time. Moreover, research suggests that every $1 invested (both by the city and by individuals) leads to an estimated net annual saving in health costs of between $3·2 and $4·2 per person. “This increased activity is more common in young middleincome and high-income men than in other social groups. Since only 45% of Bogota’s adults are meeting guidelines for physical activity, it’s clear more needs to be done”, says Julio Dávila, a Colombian Academic from University College London (UCL) who coauthored the 2012 Lancet–UCL Commission Healthy Cities. Another initiative in Bogotá is Transmilenio, a mass-transit system launched in 2000 that uses Bus Rapid Transit technology, consisting of guided bus lanes that avoid the mass traffic jams that gridlock the city. A quarter of trips in the city are made using this network, and its introduction has not only reduced car use and commuting times, but also prompted users to walk further to fixed guided-lane bus stations than they would have previously, when buses stopped wherever requested. Less successful has been one of Bogotá’s other initiatives, the 334-km cycle path network (Ciclo-Rutas), established in 1998. Only 2% of daily journeys are made by bicycle in the city, and anecdotal evidence suggests that high death rates due to traffic accidents involving cyclists, fear of crime, and lack of secure bicycle parking are behind poor use of the network. But Dávila points out that “when you take account of Bogotá’s social problems, including the wide inequalities and woefully inadequate finances, most regard these efforts to improve physical activity and reduce obesity as successful”. Australia is also battling an obesity epidemic, with the country being fifth behind the USA, Mexico, New Zealand,
and the UK in terms of obesity rates. The epidemic costs the nation AU$50 billion every year. Data from Australia show that, after adjusting for age, adults living in the most disadvantaged areas had the highest prevalence of overweight and obesity (66%), whereas those living in areas of least disadvantage had the lowest prevalence (55%). Obesity (rather than overweight) shows a particular bias towards poorer areas—obesity rates in both men and women that are double those in the most affluent areas. Thus it could be said that it is pockets within cities, not entire cities, that are facing obesity epidemics. Furthermore, Sydney, which hosted the 2000 Olympic Games, does not have the lowest obesity or highest physical activity rates. These accolades are held by Perth, WA, and Canberra, ACT.
“...it is pockets within cities, not entire cities, that are facing obesity epidemics.” “This mostly reflects the higher levels of affluence in those cities and the better infrastructure for active transport, such as Canberra’s bicycle network”, says Adrian Bauman, an expert on physical activity from the University of Sydney. He decries that “No cities or state level jurisdictions in Australia are really tackling nutrition policy definitively”, and blames the many vested interests in the food industry. He says Australia is making genuine efforts nationally to target obesity through the running campaigns of the Federal Government’s Australian National Preventive Health Agency (ANPHA). One such campaign was Swap It Don’t Stop It , which ran from 2010 until 2012, similar in its nudge approach to small behaviour change to the Change 4 Life campaign recently launched by the UK Government, which has come in for heavy criticism because of its close working connection with the food industry.
“We have created communities and cities that are dominated by cars. We need to change this situation and design communities that promote walking and cycling”, says Fiona Bull, from the University of Western Australia, who gave a special presentation on physical activity at the World Economic Forum meeting in Davos-Klosters, Switzerland in January, 2013. But she is optimistic about the future. Bull points to community work being undertaken in both the UK and Australia to target food-related planning approvals such as new takeaways in a given area. And, as in New York City, voices in these countries are getting louder on sugarsweetened beverages. “The Heart Foundation and Cancer Council of Australia have come out very strongly in favour of banning, restricting, or taxing sugared and sweetened beverages. This is a policy initiative which is likely to influence total energy intake but is one which no state or national jurisdiction is willing to tackle at a policy level yet”, adds Bauman. Even Coca-Cola has entered the obesity debate, and is currently running a mass-media campaign that includes statements such as “beating obesity will take action by all of us, based on one simple, common-sense fact: all calories count, no matter where they come from”, followed by pointing out it offers a range of lowcalorie and zero calorie beverages. But the Center for Science in the Public Interest (CSPI, an American advocacy organisation targeting food, health, and alcohol policy) has been dismissive of Coca-Cola’s involvement. A CSPI spokesman said that “what the [sugar-sweetened beverage] industry is trying to do is forestall sensible policy approaches to reducing sugary drink consumption, including taxes, further exclusion from public facilities, and caps on serving sizes such as the measure proposed by New York’s Mayor Michael Bloomberg”.
Tony Kirby
www.thelancet.com/diabetes-endocrinology August 2013
