Report on Round Table: Obesity and the quest for affluence

St Anne’s College, Oxford,  March 9-15th 2008.

The Oxford Round Table
It was an amazing experience to spend a week at Oxford University in the company of 36 other people brought together from all over the world to debate the topic of obesity.  Participants came from Scandinavian countries, the USA, Germany, Africa, Eastern Europe, one from Australia and two of us from New Zealand. 

The Oxford Round Table was founded in 1989 as a colloquium for small groups of governmental and business leaders to engage in discussions of contemporary public policy that affect nations and states worldwide.  Alumni of the Round Tables include Government Ministers, legislators, corporate business leaders, university professors and presidents, lawyers, nurses, physicians and other professionals.  The Oxford colleges with their beautiful mediaeval dining halls, chapels and libraries provide a wonderful venue for relaxed exchange of ideas and opinions.  Participants are invited from all over the world and come together for one week of intense discussion and deliberation on a particular topic.  For the week I attended the topic was “Obesity and the affluent society: The quest for treatment.”  

To spend a week at Oxford University in early spring was an extraordinary privilege and whilst we worked hard we were also treated to a wonderful “Oxford experience”.  This included meetings in the Rhodes Scholars’ building, attending a sung service in Christ College cathedral, dining in the hall familiar to Harry Potter fans and hours of walking through extraordinarily ancient vistas.  Evening sessions included coffee and port and numerous receptions and other formalities completed the experience.  We slept in the students’ rooms; they were on holiday mostly, but we enjoyed the remarkable vision of remaining students strolling the quadrangles in high collar white shirts and short black academic gowns.  Those sitting the final exams could be seen in gowns and also wearing the red rose, which signifies final exam attendance and is compulsory!!!  I tried in vain to imagine such a thing in New Zealand.

Jenny at the Centre for Rhodes Scholars

An additional bonus of the whole experience was the degree to which participants bonded as a group.  It was unlike any other conference I have ever attended with people from very different backgrounds developing immense rapport as the week wore on.  The majority of those present were academics but there were also doctors, politicians, some policy people, four nurses and an economist.  Of the nurses present, two were academics and two were in practice including one NP from the US.  The academics represented a variety of disciplines including nutrition, biosciences, exercise physiology, sociology, public health, medicine and nursing.  The format involved a little more than half the participants of the Round Table presenting short papers followed by a facilitated discussion.

An early presentation was given by Dr Stefan Winter (a physician and a Secretary of State) from Germany.  As a physician and politician he was interested in how rarely policy is evidence based.  He noted that health and wealth are closely inter-related and considers that Governments must move beyond considering health as a cost to Governments but instead as their greatest resource.  He considers that investment in health in all of its complexity requires the linking of all political domains and that getting health right is central to the success of all other endeavours.

As the week wore on major themes arose.

Genetics
It was noted by a number of speakers that the long suspected (but always resisted) genetic contribution to body size variation is becoming a little clearer.  The science in the area of obesity has moved beyond considering genetics as a poor excuse for bad behaviour(!!) to an explanatory model which is as yet imperfectly understood.  Work on the thrifty gene was noted by Dr Peter Sullivan, Head of the Department of Paediatrics, University of Oxford.  He discussed the possibility of permanent genetic alteration in the presence of maternal starvation and the discovery that the thrifty gene can actually be passed down through generations.  This raises interesting thoughts about the period in medical history when pregnant women were carefully told that they were not eating for two and urged to avoid additional weight gain in pregnancy.

Clinical management
One major clinical debate included the usefulness or otherwise of the BMI.  It was argued by many that the BMI is a very imperfect measure and can give an entirely false picture of actual body composition.  Others argued that it is currently the best measure that exists and that whilst it is clearly imperfect it is accurate enough to be useful.  Still others suggested that knowing someone’s BMI was clinically irrelevant but very useful for research processes if interventions were to be compared.

In essence the debate about BMI was overshadowed by a larger debate, which involved a subject close to my own interests.  Should we focus on body size at all or should we take a health at any size focus and concentrate on access to healthy nutrition and healthy exercise for all.  Some of the debates, surfaced at the College’s own symposium (2007) on obesity, were further elaborated.  The Round Table was clearly divided in two camps on this issue.

Panic versus a realistic appraisal of the situation
Many consistently produced shock horror statistics to show that obesity is overtaking the world at an alarming pace and requires urgent attention.  Interestingly many preceded their presentations with exactly the same slides or photos collected from the internet!!  This group is convinced that the correlation between obesity and poor health is irrefutable.  The one economist present encapsulated the personal responsibility viewpoint and argued that fat people should be encouraged into “taking better charge of themselves” through the incentive of higher personal taxes or insurance premiums.  Almost all delegates present were vociferously opposed to such a stance even though many agreed with the urgency of the problem.

Other Round Table members noted that the BMI levels have been lowered to admit greater numbers and that the international problem is being exaggerated.  In addition this group acknowledges that the risks of body size variations are less than clear.  There was considerable agreement that pathologising people with a BMI below 30 was neither justified nor helpful, however it is also commonplace clinical practice.

Some speakers acknowledged the evidence that exercise whilst clearly highly beneficial to all, does not reliably produce weight loss and that at least 90 minutes daily of very vigorous exercise is required to maintain any weight loss achieved.  International evidence is fairly consistent about the ineffectiveness of exercise as a weight loss tool although one exercise physiologist suggested that research has showed it can be effective for adolescents and young adults.  To repeat however, there was no argument from any quarter that exercise and even just increased levels of movement has considerable benefits to all - regardless of size.

Many participants made presentations, which included the taken-for-granted assumption that people with obesity suffer from, at the least, low self esteem and frequently depression.  This intrigued me as last time I looked at the literature it seemed very clear that whilst obese people may well express body dissatisfaction this does not necessarily translate into low self esteem.  Nor was it clear to me that obese people have been proven to have higher levels of clinical depression that the non-obese population.  It would be interesting to do a critical literature review to see what is actually there and to find out whether this is factual or one of the many assumptions which litter the field of obesity management.

Children are clearly a special issue.  Many delegates agreed that reduction dieting and efforts towards weight loss in adults is of limited use, preferring to focus on an approach close to New Zealand’s healthy eating/healthy action approach.  Most however agreed that significant obesity in children is of great concern and many delegates shared innovative and hard-hitting programmes to clean up school canteens and increase the opportunities for children to walk or move in safe environments.  Most argued for a fundamental cultural change in which “liquid candy” (coca cola etc) is banned and high coloured, high sugar products are made unavailable.  A participant from the State of Texas, USA was leading an especially vigorous programme to enforce healthy eating and healthy actions in school from state policy to local implementation level.

Environmental issues
It was consistently noted that whereas increased levels of obesity in developed countries are seen more often in those of low socio economic status (SES), the situation in developing countries is reversed with higher SES people showing rising levels of obesity.  This situation provokes consideration of the type and quality of food consumed by different people in different areas.  It can be shown (and was from studies presented) that consumption of fast foods is prevalent in low SES groups in developed countries and first taken up by high SES groups in developing countries.   Adrian Miller from James Cook University in Queensland presented an outstanding summary of the information on the socio-economic determinants of health. 

Jenny with Dr Salome Kruger (Nutririonist) and Dr Pearl Garambene (Neo Natologist) both from Sth Africa

Those present from Africa presented the immense challenges of working in a country with emerging childhood obesity in the midst of concurrent and significant problems of starvation or food insecurity.  In particular, Dr Salome Kruger captured the complexities of working as a nutritionist in such an environment.

Nutritionists present from the United States noted many studies showing the increase in eating out, the increase in pre-prepared food and the increase in portion sizes but others argued in essence that there is little evidence that people necessarily eat more but that the composition of many diets has changed significantly.  Even so all delegates agreed that there is always a complex interaction between genetic predisposition and environmental changes.

Cellular level
Suzi Penny (from Massey University, School of Health and Human Nutrition) spoke on the importance of a wide-angle approach to a complex, multi-faceted problem.  She noted that the link of our current affluent lifestyle with increasing obesity, cardiovascular disease, type 2 diabetes and the metabolic syndrome, with the associated morbidity and mortality, has generated a large volume of research and public health interventions.  In New Zealand there are strong ethnic differences with those of a Polynesian background being at increased risk both for obesity and type 2DM and their linked detrimental health impacts.  Factors involved in this increased risk for obesity in these ethnic groups include socio economic and cultural factors as well as intrinsic.  Overall, different public health interventions have been in the form of simple dietary guidelines and ‘anti-obesity’ messages and more recently encouragement of increased physical activity, but frustratingly, with limited success.  There is more to the obesity problem than simply balancing energy intake with expenditure.  Health and wellbeing, including obesity, is the outcome of a complex interaction of biology - genetic endowment, uterine environment and the physiological mechanisms that regulate energy balance with psychosocial factors and our current obesogenic environment.  Alongside the nutritional and socio economic factors there is also an increasing body of research into the physiological factors that determine obesity and related health risks in support of the concept of a ‘lipostat’ hypothesis initially in the early 1950s.  A large body of research has identified leptin as playing a key regulatory role in energy homeostasis.  Elevated levels switch the body to a catabolic state by suppressing energy intake via its action on satiety and feeding centres in the hypothalamus in the brain at the same time as promoting dissipation of energy from the body as heat.  Since leptin is released by fat cells, this provides a feedback mechanism for regulating body energy stores.  Conversely low leptin levels result in increased food intake

Round Table Session in Progress

and reduced energy expenditure.  This initial work was performed in animal studies, but that similar mechanisms also operate in humans is seen by the identification of some cases of human obesity, which respond to leptin treatment.  However most cases of human obesity are linked not with decreased leptin levels but with increased leptin levels indicative of leptin resistance.  Over the last decade many other physiological mechanisms and molecules have been identified that regulate appetite and energy turnover in the body, and alongside human genome research that have identified some linkages established between different genes and obesity in population groups such as the Pima Indians in the USA who are at increased risk for obesity.  There is also a growing body of research on the developmental origins of health and disease.  This followed on from the early studies by Barker that linked a deprived in utero environment if this was followed by abundant energy after birth with an increased for obesity and type 2 diabetes mellitus.  An awareness of these physiological factors is important for understanding and providing effective support for those who, due to their inherent biology and dysregulation of these complex energy homeostasis mechanisms, are more vulnerable to obesity in our present obesogenic environment.

Professor Alok Bhushan from the USA described the noted link between obesity and some cancers.  He noted the Warburg hypothesis, which argues that it is imperative to revisit metabolic characteristics that favour the development of obesity and may ultimately favour the development and progression of cancer.  He alluded to but did not enlarge upon the complex phenomena in which it is difficult to tease out or differentiate the effects of low fruit and vegetable intake and low uptake of exercise from the effects of obesity per se.  This may be of particular significance in the development of cancer.

These deliberations were given further weight by a scientist from the University of Alberta, Dr Burin Ametaj, who presented cutting edge research, which is opening the way for a vaccine against obesity.  He presented a paper entitled: A Potential Vaccine against Obesity and its Side Effects: Targeting Causa Causorum.   This was an interesting paper putting forward the novel hypothesis that obesity was an inflammatory response to endotoxins, specifically bacterial lipopolysaccharide (LPS) released by gram-negative gut microbial flora in response to a high dietary fat intake.  This fits in with recent research that insulin resistance, type 2 Diabetes, obesity and increased cardiovascular disease risk have all been linked with a low grade pro-inflammatory state and increased expression of pro-inflammatory cytokines such as tumour necrosis factor (TNF-a) and interleukin 1 and 6 ( IL-1 & IL-6).  This could potentially lead to a completely new approach to obesity and its related problems in a similar way to current interventions for gastric ulcers with the identification of Helicobacter pylori as the key causative factor.  It will be interesting to see further developments in this area and relevance to human obesity and diabetes.  The studies reported were done with ruminants, whose digestive tract is significantly different from the human digestive system.  Their rumen microbial flora make them much more susceptible to detrimental effects including GI tract wall damage and the potential LPS leakage into the blood stream which would trigger such an inflammatory response.  The positive results reported for rodents, whose digestive system is more like the human’s one, used a very high fat diet (72%), much higher than the average 40% or so fat content of most ‘western’ human diets.  If this hypothesis does prove to have direct relevance to human obesity theoretically a vaccine could be developed.  Perhaps the beneficial effects of dietary fibre, low glycemic index and glycemic load, generous amounts of fruit and vegetables and low intake of saturated fat content may be in part via their effect on the digestive system microbial flora and another good reason for advocating these food choices. 

 
Conclusion
Dr Alice Running, a Nurse Practitioner from Nevada gave a wonderfully clear presentation, which developed the ideas of innovative disruption drawing on the ovular work of Christensen, Bauman and Kenagy in the Harvard Review.  She argued that current models of health service delivery, in the States particularly, do not foster prevention and do not create opportunities to work with people in constructive, positive and health promoting ways especially relevant to areas of body size and exercise.  Her ideas could be seen as relevant to all aspects of the week of discussions.

I have to note that I cannot remember a week in my life where I have been consistently offered quite so much food, quite so often and quite so much wine and port.  This perhaps encapsulates one of the chief ironies of this whole “obesity” phenomenon.  I observed the very many skinny people present (some fresh from making impassioned pleas from the podium about our eating habits) happily loading their plates and filling their glasses at every opportunity.  Ironically these were sometimes the very ones who most complained at the many miles we walked (luckily!) between venues.

Acknowledgement
To:  Suzi Penny (from Massey University, School of Health and Human Nutrition) for sharing her notes on her own paper and that of Burim Ametaj.