Wh a t is o b e sity a n d wh a t is its im p a c t?

23
H o w is we ig h t c o n tro lle d ? I s o b e sity in o u r g e n e s ? 45
H o w d o e s life style a n d e n viro n m e n t im p a c t
o n o u r we ig h t? 6
R e a l vo ic e s: o b e se p e o p le a n d a n o b e sity
d o c to r h a ve th e ir sa y 7, 1213
H o w c a n we tre a t o r p re ve n t o b e sity? 1011
Wh o se re sp o n sib ility is it to ta c k le o b e sity? 1415
T h e b ig p ic tu re 16
T h is is th e e ra o f th e e x p a n d in g wa istlin e . O ve r
th e p a st fe w d e c a d e s we h a ve b e e n ste a d ily p ilin g
o n th e p o u n d s. O n e in ve a d u lt m e n a n d o n e in
fo u r a d u lt wo m e n a re o b e se . A sta g g e rin g two -
th ird s o f a ll m e n a n d h a lf o f a ll wo m e n a re e ith e r
o ve rwe ig h t o r o b e se th a t s 2 4 m illio n p e o p le .
G lo b a lly, m o re th a n 3 0 0 m illio n a d u lts a re o b e se .
BigPicture
Newspapers warn of an obesity timebomb:
o b e sity m a y b e a b o u t to o ve rta k e sm o k in g
a s th e m a jo r c a u se o f p re ve n ta b le d ise a se ;
our children are growing up to be couch potatoes,
putting down Playstations only long enough to
pick up the TV remote control, or the telephone
to order another pizza.
B u t wh y is o b e sity su c h a p ro b le m ? Is it just
a personal matter? Are we simply prejudiced
against heavier people?
And if there is a problem, who should be doing
something about it? I s it ju st d o wn to p e o p le
to sh o w m o re se lf-c o n tro l? Should food
manufacturers be more responsible about what
they put in their products or in how they market
them? What about schools and parents?
Or should governments intervene, slapping on
fat taxes or banning fast food advertisements?
And what have science and medicine to say?
A re we lik e ly to se e wo n d e rd ru g s th a t k e e p
u s slim n o m a tte r wh a t we e a t? How well do
we understand the human physiology that controls
our weight? Or the psychological factors that
inuence what (and why) we eat?
This interplay between science, medicine and
society, and people, institutions and politics,
forms the focus of this Big Picture.
OBESITY on
ISSUE 1 JANUARY 2005
T h e Big Picture se rie s is th e su c c e sso r to LabNotes.
U p -to -d a te sc ie n c e . R e a l-life issu e s. F o r te a c h e rs
a n d stu d e n ts. A u th o rita tive , b a la n c e d a n d
a c c e ssib le , th e Big Picture se rie s is th e e sse n tia l
g u id e to b io m e d ic a l sc ie n c e a n d its so c ia l im p a c t.
R
e
x

F
e
a
t
u
r
e
s
2 | BIG PICTURE 1
O b e sity is a sig n o f e x c e ss fa t sto ra g e b y th e b o d y. T h is c a n in c re a se
th e risk o f m a n y se rio u s h e a lth p ro b le m s. O b e sity is u su a lly c la ssi e d
a s a d ise a se , b u t we se e m to h a ve little sym p a th y fo r o ve rwe ig h t p e o p le .
E d u c a tio n e d ito r: Hannah Russell
E d u c a tio n a d vise r: Peter Finegold
E d ito r: Ian Jones
Write rs: Jackie Adam, Penny Bailey,
Lisa Melton, Julie Reza
I llu stra to r: Glen McBeth
E d ito ria l a d viso ry b o a rd : Nan Davies,
Nick Finer, Susan Jebb, Wing-May Kong,
Dean Madden, Michael Reiss, Neville Rigby,
Dell Stanford
All images, unless otherwise indicated, are from
the Wellcome Trusts Medical Photographic Library.
The Wellcome Trust is an independent biomedical
research funding charity (registered charity no. 210183).
The Trusts mission is to foster and promote research
with the aim of improving human and animal health.
Reecting the profound impact todays research will
have on society, the Wellcome Trust also seeks to raise
awareness of the medical, ethical and social implications
of research and promote dialogue between scientists,
the public and policy makers.
The Trustee of the Wellcome Trust, London, 2004.
All rights reserved. Except as set out below, no part
of this publication may be reproduced, stored in a
retrieval system, or transmitted, in any form or by any
means, electronic, mechanical, photocopying,
recording or otherwise, without the prior permission
of the Wellcome Trust.
The Wellcome Trust consents to photocopies of all
or part of this publication being made by educational
institutions for non-prot, educational classroom use
provided that the above copyright notice and any
credits attaching to images or text featured in the
photocopy appear clearly in such a photocopy.
MC-3267.p/30K/012005/SW
DIABETES
Ve ry stro n g lin k with
o b e sity. R e la tive risk
rise s ra p id ly with
we ig h t, p a rtic u la rly
in wo m e n
HIGH BLOOD
PRESSURE AND
CORONARY
HEART DISEASE
R isk in c re a se d
3 4 -fo ld in o b e se
p e o p le
CANCER
I n c re a se d risk fo r
c a n c e r o f th e c o lo n ,
b re a st p o st-
m e n o p a u se ) , wo m b ,
k id n e y a n d o e so p h a g u s
STROKE
O b e sity d o u b le s th e
risk o f stro k e
The increasing size of people is having other
effects. One airline has introduced a policy
that larger persons pay for two seats; hospitals
have had to purchase larger beds, bigger
commodes, and wider wheelchairs for their
patients, and nally, with death, comes bigger
cofns and wider burial plots.
Clothes sizes are going up: in 2000, Marks
and Spencer relabelled its womens size 14
as size 12. Childrens clothes now have to be
made in larger sizes.
On the other hand
Some insist that obesity is neither a disease,
nor does it necessarily signify poor health.
A portly but t person may well be healthier
than somebody who is slim but inactive. The
exact amount of ill-health attributable to obesity
is not certain.
Others argue that we are unnecessarily
obsessed with weight, driven by commercial
interests keen to exploit a popular desire to be
thin. Finally, m a n y p e o p le a re h a p p y to b e fa t .
SIZE MATTERS
FAST
FACT
T h e d e m a n d
fo r re a d y-
m e a ls in th e
U K g re w b y
4 4 %
b e twe e n 1 9 9 0
a n d 2 0 0 2 .
Does it matter?
The medical consensus is that o b e sity h a s
se rio u s im p lic a tio n s fo r h e a lth . It is associated
with increased risk for a variety of disorders,
including type 2 diabetes, high blood pressure,
stroke, heart disease and cancer (Figure 1).
It can also impact on q u a lity o f life (infertility,
mobility problems and sleep disorders). And
it can have p syc h o lo g ic a l c o n se q u e n c e s,
such as lowered self-esteem, anxiety and
clinical depression though, arguably, these
may be more related to the social stigma
attached to obesity than obesity itself.
In the USA, the Centers for Disease Control
and Prevention have said that o b e sity is
c lo sin g in o n sm o k in g a s th e m o st
im p o rta n t c a u se o f p re m a tu re d e a th .
And it is not just a personal issue. The
e c o n o m ic c o sts are substantial, with recent
estimates suggesting that between 2 and 8
per cent of sick care costs in Western countries
are attributable to obesity an amount
comparable to that spent on cancer therapy.
F I G U R E 1 : M A J O R H E A LT H R I S K S
A S S O C I AT E D WI T H O B E S I T Y.
JANUARY 2005 | 3
Why is obesity bad for you? How does it cause diabetes or increase
the risk of cancer? F in d o u t a t B ig P ic tu re O n lin e
www. we llc o m e . a c . u k /b ig p ic tu re /o b e sity
T h e e n e rg y c o n te n t o f fo o d is u su a lly
e x p re sse d in k ilo jo u le s k J ) . T h e se u n its a re
su p e rse d in g th e fo rm e r te rm , th e c a lo rie .
D iffe re n t p a rts o f fo o d h a ve d iffe re n t
e n e rg y d e n sitie s:
B e c a u se o f its h ig h e n e rg y d e n sity, fa t is a n
e x c e lle n t wa y o f sto rin g e n e rg y in th e b o d y.
T h e p e o p le in E n g la n d
a re g e ttin g fa tte r. . .
. . . a n d th a t s n o t g o o d n e ws
fo r th e ir h e a lth
0
5
% of English population
10
15
20
25
1980 1993 2000 2002
0
1
2
Relative risk
Body mass index
3
4
5
6
21 22 23 24 25 26 27 28 29 30
Diabetes
Women
Women
Men
Men
Heart disease
T H E I N C R E A S I N G S I Z E O F P E O P L E
M E A N S B I G G E R C O F F I N S A R E N E E D E D .
Rex Features
T h e m e d ia h a ve a lso fu e lle d th e c u rre n t
n e a r-h yste ria a b o u t o b e sity. T h e o b e sity
tim e b o m b m a k e s fo r g o o d h e a d lin e s, a n d
th e re is a stro n g h u m a n in te re st a n g le th a t
c a n se ll n e wsp a p e rs. Wh y h a s it su d d e n ly
b e c o m e a n issu e ? I n 1 9 6 6 , wh e n th e U S
P u b lic H e a lth S e rvic e d e c la re d o b e sity a
m a jo r h e a lth p ro b le m , it p a sse d u n n o tic e d .
Ye t th e m e d ia s wa r o n o b e sity p re se n ts
m a n y d if c u ltie s. N e wsp a p e rs wa n t to
in c re a se sa le s, a n d th a t c a n le a d to
se n sa tio n a lism a t th e e x p e n se o f a c c u ra c y.
T h e m e d ia p ro m o te slim n e ss p re d o m in a n tly
in te rm s o f b e a u ty, ra th e r th a n a s a ro u te
to lo n g -te rm h e a lth .
A lso , d e m o n isin g o b e sity m a y a c tu a lly b e
c o u n te rp ro d u c tive e n c o u ra g in g fe e lin g s
o f in a d e q u a c y o r u n h a p p in e ss th a t m a y
we ll a ffe c t e a tin g p a tte rn s. P ro m o tin g
u n re a listic b o d y fo rm s a s d e sira b le c o u ld
h a ve a sim ila r im p a c t.
T h e ste re o typ e d vie w is th a t fa t p e o p le e a t
c a k e s a n d c risp s a ll d a y th e y a re g re e d y,
slo th fu l a n d la c k se lf-c o n tro l. We a re h o o ke d
o n a p p e a ra n c e s, b u t a re th e m e d ia to b la m e ?
I m a g e s in n e wsp a p e rs, m a g a zin e s a n d
te le visio n g lo rify slim n e ss. R a k e -th in
c e le b ritie s lik e K a te M o ss a n d Vic to ria
B e c k h a m e x u d e g la m o u r. G o ssip
m a g a zin e s m a rve l a t th e sve lte g u re s o f
a c tre sse s a n d lm sta rs, o r th e ir a b ility to
lo se we ig h t a fte r g ivin g b irth .
F a t is d iffe re n t. T h e m e d ia d e m o n ise a b .
C e le b ritie s with e ve n a h in t o f fa t a re m o c ke d
fo r a p p e a rin g sc a n tily c la d o n th e b e a c h .
F e w p e o p le m a n a g e to o ve rc o m e fa ttism :
c o m e d ia n D a wn F re n c h is a ra re e x c e p tio n .
OBESITY AND THE MEDIA
ENERGY
What is obesity?
How do we know if someone is
overweight or obese? The ideal
approach would be to measure
body fat levels directly. Unfortunately,
this is hard to do without specialist
equipment, so b o d y m a ss in d e x
(BMI) tends to be assessed instead.
B M I is e a sy to m e a su re a n d is m o re
u se fu l th a n o th e r sim p le m e a su re s
(such as waist circumference, waist-
hip ratio, skinfold measurements).
But BMI is best used as a guide
to fa t le ve ls in th e g e n e ra l
p o p u la tio n ra th e r th a n in in d ivid u a ls.
For instance, athletes typically have
high BMIs despite having little body
fat (muscle is heavier than fat).
Also, ideal BMI thresholds may not
hold for young children, the elderly,
or for people of different ethnic
backgrounds.
BMI
U n d e rwe ig h t L e ss th a n 1 8 . 5
N o rm a l ra n g e 1 8 . 5 2 4 . 9
O ve rwe ig h t 2 5 2 9 . 9
O b e se > 3 0
Percentage of the male (left) and female
(right) population who are obese or severely
obese (dark shade).
Increased risk for two common diseases
as BMI increases.
Caution: S ta tistic s u su a lly h id e a s m u c h a s th e y re ve a l. F o r e x a m p le , h e a lth risk s increase a t B M I
le ss th a n 1 9 . An d in o ld e r p e o p le , h ig h e r B M I m a y b e a n advantage. M o re o n th is in B ig P ic tu re O n lin e .
STATS CORNER
BACKGROUND
C a rb o h yd ra te :
17 kJ/g
F a t: 38 kJ/g P ro te in : 17 kJ/g
A lc o h o l: 29kJ/g
4 | BIG PICTURE 1
The energy balance
The number of calories we
take in is offset by the number
we use up. Anything left over
is stored.
Energy (in)

Energy (spent)
=
Energy (stored)
I n sim p le te rm s, p e o p le g a in we ig h t wh e n th e y c o n su m e m o re e n e rg y th a n th e y u se . O ve r tim e ,
th e im b a la n c e will le a d to e x tra fa t sto ra g e . H o w th is p la ys o u t will d iffe r b e twe e n in d ivid u a ls,
with e n viro n m e n ta l, p h ysio lo g ic a l, p ysc h o lo g ic a l a n d g e n e tic fa c to rs a ll p la yin g a p a rt.
METABOLISM
HOW IT WORKS...
A ne balance
Body weight is a n e ly c o n tro lle d syste m . We need
to have enough stored energy to survive even if we
miss a meal or two, but not so much that we carry
pounds of excess body fat.
Honed by millions of years of evolution, this system
is extraordinarily sophisticated. During a typical year,
we consume around a million calories. Generally,
our weight at the end of the year is fairly close to
what it was at the beginning so th e b o d y h a s
b a la n c e d e n e rg y in ta k e a n d u se to a n a c c u ra c y
o f le ss th a n 1 p e r c e n t. This is far superior to our
attempts to consciously regulate calorie intake.
The key to this monitoring is a c o m p le x n e two rk o f
c h e c k s a n d b a la n c e s, involving hormones and the
nervous system, that regulates appetite, exercise
and rest, storage of energy, and cellular metabolism.
We dont fully understand how this system works,
but it seems to create two important fe e d b a c k
lo o p s: if our weight drops, it promotes greater
intake of food; and if our weight goes up, it stimulates
changes that should drive weight down, such as
speeding up body metabolism.
Loss of weight is resisted by the body particularly
powerfully. This is thought to be an evolutionary
survival mechanism, to ensure survival in times
of famine. The brain automatically slows down the
bodys metabolic rate, reducing the number
of calories burned. And, of course, we feel more
hungry, so seek out food.
From this perspective, it is not surprising that most
casual diets end in failure. It may not be a failure
of will power but the automatic effect of an a n c ie n t
su rviva l m e c h a n ism .
The complex systems controlling body weight and
energy use are coordinated by the brain. Like all
metabolic systems, they can be disrupted, leading
to effects on weight. Some prescribed drugs (e.g.
steroids and some antidepressants), for example,
can cause weight gain as a side-effect.
L O S S O F WE I G H T I S R E S I S T E D B Y T H E
B O D Y P A R T I C U L A R LY P O WE R F U L LY.
Weight-
lowering
mechanisms
triggered
Weight
goes up
Weight
goes down
Weight
goes up
Weight
goes down
Weight-
raising
mechanisms
triggered
Normal
weight
range
T H E F E E D B A C K L O O P S I N VO LVE D I N B A L A N C I N G
E N E R G Y I N TA K E A N D U S E .
Genetic influence
1 . M e la n o c o rtin re c e p to r
2 . L e p tin
Drug treatment
1 . Sib u tra m in e
2 . O rlista t
Stomach and
digestive system
D ig e sts fo o d ,
a b so rb s fu e l m o le c u le s
Sig n a ls fu lln e ss to b ra in
Fat tissue
Sto re s e n e rg y
Se n d s sig n a ls to b ra in /
b o d y tissu e s e . g . le p tin )

F
u
l
l
n
e
s
s

C
h
e
a
p
,

p
l
e
n
t
i
f
u
l
,

e
n
e
r
g
y
-
r
i
c
h

f
o
o
d A
d
v
e
r
t
i
s
i
n
g
,

p
e
e
r

p
r
e
s
s
u
r
e

e
t
c
.
E
n
e
r
g
y

u
s
e
E
n
e
r
g
y

u
s
e
M o n ito rs b o d ys
e n e rg y le ve ls
C o n tro ls e n e rg y u se
L ive r
G LYC O G E N
M
u
s
c
l
e
G
L
Y
C
O
G
E
N
F
a
t

t
i
s
s
u
e
T R I G LYC E R I D
E
F O O D I N TA KE
E m o tio n s
E n e rg y F u lln e ss
R e wa rd p a th wa ys
T H E B R A I N :
Integrates signals
Controls eating behaviour
ABOVE
C O N T R O L O F E N E R G Y
I N TA K E . I N T E R N A L
P H YS I O L O G I C A L ) A N D
E XT E R N A L F A C T O R S
I N F L U E N C E O U R I N TA K E
O F E N E R G Y E AT I N G )
A N D U S E O F E N E R G Y
M E TA B O L I S M A N D
E XE R C I S E ) .
JANUARY 2005 | 5
Three-year-old dies of obesity
screamed the newspaper headlines
when, in May 2004, a child died from
heart failure in a London hospital.
She weighed a staggering 40 kg.
A media frenzy erupted, and the
parents were blamed for stufng
her to death.
Was it fair to accuse her parents?
Scientists later conrmed that there
was a medical problem behind the
childs extreme obesity: a genetic glitch
that triggered her immense appetite.
Genes play a crucial role in shaping
our weight, but scientists have only
recently started to work out how.
It is too simple to say that obesity
is all in the genes but our genetic
inheritance does have a big say in
our size.
Researchers can come at obesity
from two directions. In a classical
approach, the extent to which
weight or obesity is inherited can
be assessed. This is a difcult area
to study, but the consensus is that
there is a h ig h d e g re e o f h e rita b ility
in b o d y we ig h t.
Obesity genes
A newer approach is to track down
the g e n e s in vo lve d in o b e sity.
Of course, no gene exists just to make
people fat. But, on rare occasions,
someone may inherit a mutation
that leads to excess weight gain.
The rst evidence of this came from
a very fat mouse.
These ob (obese) mice weigh
almost three times as much as
normal mice. They were found to
In 2002, a London team headed by Professor Steve Bloom caused much excitement when they
reported in the journal Nature that a molecule called PYY3-36 made rats less hungry; they ate less
and got thinner. The molecule even seemed to work on people, in a small clinical trial. But in 2004,
another group reported that they could not get the same results with PYY3-36. What was going
on? And what does the dispute say about modern science? F in d o u t a t B ig P ic tu re O n lin e .
www. we llc o m e . a c . u k /b ig p ic tu re /o b e sity
Obesity and genes
A d o lp h e Q u e te le t a B e lg ia n a stro n o m e r,
m e te o ro lo g ist, so c io lo g ist, m a th e m a tic ia n a n d
sta tistic ia n wa s th e rst sta tistic ia n to u se
th e n o rm a l d istrib u tio n c u rve u se d to m e a su re
e rro rs in a stro n o m y) to m o d e l h u m a n va ria tio n .
T h e n o rm a l d istrib u tio n c u rve ta k e s th e sh a p e o f a b e ll o r
h u m p o f a c a m e l. T h is re e c ts th e fa c t th a t m o st sc o re s
fo r h e ig h t, we ig h t, e x a m in a tio n re su lts, o r wh a te ve r is b e in g
m e a su re d in a p o p u la tio n ) c lu ste r a ro u n d th e m id d le p o in t
th e to p o f th e c u rve ) . E x tre m e va lu e s a re fa r m o re in fre q u e n t,
a n d a re re p re se n te d b y th e sid e s o f th e c u rve .
Q u e te le t u se d th e n o rm a l d istrib u tio n a s a b a sis o f h is c o n c e p t
o f th e a ve ra g e m a n , l h o m m e m o ye n th e id e a l fro m wh o m
m o st o f u s d e via te a c c o rd in g to th e n o rm a l d istrib u tio n .
Q u e te le t a lso d e vise d a m e a su re o f b o d y m a ss, n o w k n o wn a s
Q u e te le t s in d e x , o r th e b o d y m a ss in d e x B M I ; se e p a g e 3 ) .
FAST
FACT
Yo u n g c h ild re n
wh o se p a re n ts
a re o ve rwe ig h t
a re 13 to 15
times more
likely to
b e c o m e o b e se
yo u n g a d u lts
re g a rd le ss o f
th e c h ild s
c u rre n t we ig h t.
Beyond leptin
Digging deeper, scientists have
now found more than a dozen genes
that, if mutated, may predispose
people to obesity.
The gene for the m e la n o c o rtin
re c e p to r is a promising candidate,
since around six per cent of young
children with severe obesity have this
gene disrupted. F ive o th e r g e n e tic
m u ta tio n s th a t c a u se o b e sity in
c h ild re n h a ve b e e n p in p o in te d .
However, these are still rare cases,
in which weight control has gone
drastically wrong. They are unlikely
to explain most individual differences
in weight gain in children and adults.
The likelihood is that there are a
small number of genes that have
a major impact in a few cases,
and a much larger number of genes
(perhaps 200300) that have smaller
effects in a larger number of people.
The genes could be involved in
any part of the bodys complex
mechanisms of weight regulation.
Over time, even minor variations
could have a big impact on weight.
be missing a hormone, which was
called le p tin (from leptos, the
Greek for thin). The defect was
down to a mutation in the ob gene.
Mice without leptin had an insatiable
appetite. But when leptin was injected
into ob mice, they returned to normal
in less than a month. L e p tin th u s
a p p e a rs to switc h o ff h u n g e r.
So much for mice: what about
humans? In Cambridge, researchers
had been referred two cousins who
had an intense drive to eat; they were
exceptionally obese. Sure enough,
the children shared the same genetic
mutation as the ob mice. When
given leptin, their appetite went down
and they began to lose weight.
Leptin was instantly hailed as an
obesity wonder drug. But
disappointment soon followed.
M o st o b e se p e o p le d o n o t la c k
le p tin quite the contrary. They
have even more than normal people,
but the body does not seem to
respond to it. So giving people leptin
does not help them lose weight.
G E N E S P L AY A C R U C I A L
R O L E I N S H A P I N G O U R
WE I G H T
A FAMOUS BELGIAN
Friend or foe?
Fat gets a bad press. But fa t h a s im p o rta n t b io lo g ic a l ro le s.
I t is a wa y o f sto rin g e n e rg y. It also pads and protects our
organs and helps us to keep warm. Fat molecules are needed to
make cell membranes and to transport vitamins around our body.
But excess body fat in the wrong place can be bad. Fat is laid
down to give two main body shapes a p p le or p e a r. Men tend
to be apples, women pears; as fa t tissu e a ro u n d th e a b d o m e n
is p a rtic u la rly stro n g ly lin k e d to h e a lth p ro b le m s, men tend
to be at greater risk than women. After the menopause, though,
women tend to become apple-shaped, increasing their risk.
ABOVE
T H E OB M U TA N T
M O U S E R I G H T )
D WA R F S I T S
N O R M A L
R E L AT I VE S .
J Friedman/J Bonner
ON THE W
EB
6 | BIG PICTURE 1
The nature versus nurture debate
has raged for decades. For human
characteristics, the choice has been
between biological destiny (the
nature part) or upbringing and
environment (nurture).
So what exactly is nature these days?
These days it has come to mean in
our genes or, perhaps, h a rd wire d
in to o u r b ra in s: there is little we can
do to change the outcome.
And nurture? This used to reect
the way we were brought up, the
way we were treated by our family,
the values we learned as we grew
up all things that moulded our
biology and could be altered. Now
we have th e e n viro n m e n t, which
includes things like peer groups,
social pressures, pollution, infections
and so again, all factors outside
us that may have a lasting impact.
Nowadays, very few people stick to
such an either/or view of the world.
Crucially, the distinction between
nature and nurture its either one
or the other is rarely if ever true.
Most biological traits are inuenced
by both. Not only that, but they are
also bound up with one another:
the inuence of genes will depend
on the environment and vice versa.
For obesity, th e n a tu re a rg u m e n t
sa ys th a t o u r size is g o ve rn e d b y
o u r g e n e s. If we are destined to be
large, then large we will be. The
nurture viewpoint is that it is down
to the food we consume and how
much exercise we take both things
we can do something about.
Clearly, some cases of obesity are
due to nature. If you are unfortunate
enough to inherit a mutation in your
leptin gene, it is almost certain that
you will grow up to be obese.
On the other hand, if you are born in
a poor urban area, yo u r e n viro n m e n t
will g re a tly in c re a se yo u r c h a n c e s
o f b e c o m in g o b e se , whatever
genes you have.
Most of us sit somewhere in the
middle: our genes, acting through
complex biological processes,
inuence our size; so does the
environment in which we are brought
up the views of our parents, our
friends and the availability of food.
S o th e wh o le situ a tio n is m u c h
m o re c o m p le x th a n so m e tim e s
p o rtra ye d . The effects of genes,
for example, will often be quite
subtle. They may predispose to a
condition or trait, but do not make
it inevitable. Yes, eating less will
lead to weight loss, but the bodys
biological response to this change
cannot be ignored.
T h is is a c o m p le x n e two rk o f
in te ra c tio n s, which science is only
just beginning to untangle. Our
understanding of the bigger picture
is still far from complete.
Drug treatments target the biology
of this network; health campaigns
and political policies tackle the
environmental contributions. Effective
long-term solutions are going to
need to recognise the complicated
relationships between these factors,
and a host of genetic, psychological,
social and political factors.
WEIGHT
DEBATE
T h e n a tu re ve rsu s n u rtu re d e b a te o b sc u re s im p o rta n t
p o in ts a b o u t c o m p le x h u m a n tra its.
Raising the OBs
T h e B ig P ic tu re o n O b e sity
o n lin e a c tivity
A c c e ss R a isin g th e O B s a t
www.wellcome.ac.uk/bigpicture/obesity
Yo u h a ve b e e n g ive n re sp o n sib ility
fo r lo o k in g a fte r a yo u n g c re a tu re ,
a n O B . U n fo rtu n a te ly, th e y h a ve a
te n d e n c y to b e c o m e o b e se . E ve n
wo rse , th e y h a ve a m in d o f th e ir
o wn . C a n yo u rise to th e c h a lle n g e
o f ra isin g a h e a lth y O B a n d so
d isc o ve r th e c a u se s o f th e ir su p e r-
size p ro b le m ?
T h is Big Picture on Obesity h a s a n
a c c o m p a n yin g we b -b a se d a c tivity
The OBs. Yo u r ta sk is to p a re n t a
yo u n g c re a tu re a s it g ro ws, c h o o sin g
its d ie t, m a n a g in g its a c tivity.
B u t b e wa re : yo u r O B m a y n o t
b e k e e n o n to fu a n d sa la d a n d
swim m in g 1 0 0 le n g th s b e fo re
b re a k fa st. A n d yo u m a y n d life
th ro win g a wh o le h e a p o f to u g h
c h a lle n g e s a t yo u .
Yo u r O B c o m e s with a n in b u ilt
g e n e tic in h e rita n c e , wh ic h a ffe c ts
h o w it in te ra c ts with yo u a n d its
e n viro n m e n t. A ll th e se in u e n c e s
will im p a c t o n its n a l size .
A fte r yo u ve trie d b rin g in g u p o n e
O B , yo u th e n g e t th e c h a n c e to
in ve st re so u rc e s to h e lp a ll O B s
sta y h e a lth y. Wh a t a re yo u g o in g
to sp e n d yo u r m o n e y o n ? G e n e tic
e n g in e e rin g ? C o m b a tin g p o ve rty?
O B p a re n tin g c la sse s?
Teachers: T h e g a m e will e n a b le stu d e n ts
to e x p lo re fo r th e m se lve s h o w g e n e s,
u p b rin g in g a n d e n viro n m e n t a ffe c t we ig h t
g a in . T h e g a m e is d e sig n e d to ta k e a b o u t
a n h o u r o f le sso n tim e , a n d in c lu d e s a n
o p tio n a l e x te n sio n a c tivity. T h e we b site
in c lu d e s g u id a n c e fo r te a c h e rs.
This activity has been developed by the
Centre for Science Education at Shefeld
Hallam University.
ONLINE ACTIVITY
www.wellcome.ac.uk/bigpicture/obesity
JANUARY 2005 | 7
D o e s so c ie ty p re ssu re p e o p le to
b e a p a rtic u la r size a n d sh a p e ?
Yes. Research shows that obese people applying
for jobs are less likely to succeed even if they are
applying to be a VDU [visual display unit] operator,
in a back room, with no contact with the public.
S h o u ld n t p e o p le b e fre e to c h o o se
th e life style s th e y wish , e ve n if
th e y e n d u p o ve rwe ig h t o r o b e se ?
Yes. But society and doctors also have a
responsibility to draw attention to unhealthy lifestyles
and help people who want to improve their health to
realize they can. At the moment were helping them
make unhealthy choices: high-fat foods and larger
portions are the cheap options in supermarkets.
Wh a t d o yo u th in k th e k e y
fa c to rs a re in th e g ro wth
o f o b e sity?
There are genetic factors, but changes in
the environment over the last few decades
have been the crucial key. People are
living far more sedentary lifestyles than
they did 20 or 40 years ago. Theres also
been a change in the kind of food we
eat. Today we eat far more fat and rened
sugar. These foods are very palatable
and therefore easy to over-consume.
D o yo u c o n sid e r o b e sity
to b e a d ise a se ?
It meets all the criteria for a disease. It shortens life,
causes painful symptoms and other health
complications, and puts people at risk for other
diseases. Its certainly a public health problem.
H o w b ig a p ro b le m d o yo u th in k th e
in c re a sin g in c id e n c e o f o b e sity is?
Huge. If we stopped obesity the population would be
healthier than it would be if everyone stopped smoking.
H o w m u c h c o n tro l d o yo u th in k
in d ivid u a ls h a ve o ve r th e ir o wn
sh a p e a n d size ? I s we ig h t c o n tro l
ju st d o wn to se lf-c o n tro l?
If it was, we wouldnt have the problem. This isnt
about ever-increasing numbers of people showing
less self-control. The problem is that when people try
and lose weight. They are ghting some of our most
fundamental biological processes.
To wh a t e xte n t is size in th e g e n e s ?
Wh a t d o e s th is m e a n ? H o w d o yo u
th in k g e n e s e x e rt th e ir in u e n c e ?
A number of studies in the 1960s pointed to a very
high degree of heritability, of round 40 of 60 per cent.
But obesity is rarely down to a single gene mutation.
It tends to be caused by a number of genetic variants
that come together and exert their inuence in
different ways by increasing energy intake, decreasing
expenditure, or prompting the body to store energy
as fat rather than muscle. However, environment still
plays a critical role: if theres no food available, the
mutations wont be able to exert their inuence.
Wh o d o yo u th in k sh o u ld ta k e
re sp o n sib ility?
All of us. Obese people should take responsibility
for themselves. Employers should provide a work
environment that protects people against obesity by
offering exercise facilities, and bowls of fruit instead
of biscuits at meetings. The government should
ensure that supermarkets sell healthy foods and label
the nutritional content clearly. And the medical
profession needs to be proactive in helping people
to recognise they are getting obese, explaining the
risks, and offering prevention programmes.
Which are the key organizations in obesity research, support and medicine?
F in d o u t a t B ig P ic tu re O n lin e
www. we llc o m e . a c . u k /b ig p ic tu re /o b e sity
Yo u c a n p ro te c t yo u rse lf b y b e in g p h ysic a lly
a c tive , e ve n if yo u a re o b e se . S u m o
wre stle rs h a ve h u g e a m o u n ts o f e x c e ss
we ig h t, b u t a lo t o f th is is m u sc le with fa t
o u tsid e th e a b d o m e n . H o we ve r, wh e n th e y
re tire , fa t is d e p o site d in sid e th e ir a b d o m e n s
a n d b e c o m e s m o re d a n g e ro u s.
REAL VOICES
The doctor
N ic k F in e r is a re se a rc h e r a n d H o n o ra ry
C o n su lta n t in O b e sity M e d ic in e a t
A d d e n b ro o k e s H o sp ita l, C a m b rid g e .
We a sk e d h im fo r a d o c to r s p e rsp e c tive
o n o b e sity.
Ye s, th e y sh o u ld . O b e se p e o p le a re 2 0 3 0 tim e s
m o re like ly to d e ve lo p typ e 2 d ia b e te s a n d h a ve
a two to th re e fo ld in c re a se d risk o f c a rd io va sc u la r
d ise a se . C a n c e rs o f th e b re a st, u te ru s, c o lo n
a n d p ro sta te a re a lso lin k e d to o b e sity.
S H O U L D O VE R WE I G H T /O B E S E
P E O P L E H AVE C O N C E R N S A B O U T
T H E I R F U T U R E H E A LT H
R
e
x

F
e
a
t
u
r
e
s
Wh y a re we g e ttin g fa tte r? T h e sim p le a n swe r is th a t we a re c o n su m in g to o m u c h a n d e x e rc isin g
to o little . O u r m o d e rn life style s a re b rin g in g u s in to c o n ic t with o u r a n c ie n t m e ta b o lism .
WEIGHT GAIN
FAST
FACT
A 2 0 -ye a r-o ld
o b e se m a n
c a n e x p e c t
to live
13 years
le ss th a n
th e a ve ra g e .
FAST
FACT
Yo u o n ly
n e e d to e a t
200 e x tra
c a lo rie s a
d a y a b o u t
th re e d ig e stive
b isc u its)
o ve r a ye a r to
p u t o n 10kg
b y th e e n d
o f th e ye a r.
The tn e ss a n d slim m in g
in d u strie s promote the idea that
being overweight is a bad thing and
should be remedied. While this can
lead to health benets, weight loss
is generally promoted for beauty
rather than health reasons.
The p h a rm a c e u tic a l in d u stry
b e n e ts fro m o b e sity being
recognised as a medical problem
as it can market drugs to tackle it.
In 2002, the market for anti-obesity
drugs reached $520 million
(270 million) in the USA, Europe
and Japan. Most analysts believe
this will be a multibillion dollar
industry within a decade.
All of these depend on a desire for
weight loss, so keeping body weight
in the publics eye is to their advantage.
S u p e rm a rk e ts have been blamed
for a pricing structure that makes
unhealthy food cheaper than healthy
food, and for placing unhealthy
foods in high prole positions (such
as having sweets near checkouts).
F o o d in d u stry sp o n so rsh ip of
schoolbooks and sports has also
been widely criticised.
The a d ve rtisin g in d u stry is a n o th e r
fo rc e in u e n c in g o b e sity. Millions
of pounds are spent encouraging us
to consume energy-dense food and
drinks often specically targeting
children. The money spent promoting
fruit is a tiny fraction of that spent on
advertising sweets and snacks.
Money talks
Food producers, distributors and
advertisers have all been blamed
for obesity, particularly in children.
Others, such as the slimming, tness
and pharmaceutical industries,
benet from the problem.
F o o d p ro d u c e rs n e e d to se ll
th e ir p ro d u c ts to su rvive . But many
of their products are high in fat and
hidden sugar. The industry is accused
of producing too many sweetened
and processed convenience items,
and of poor food labelling that
hinders consumer ability to choose
healthy options.
In 2002 a very overweight man
led a lawsuit against several US
fast-food chains, claiming these
had contributed to his obesity.
F a st-fo o d c h a in s have been ticked
off for super-sizing and encouraging
collection of free gifts.
M I L L I O N S O F P O U N D S A R E
S P E N T E N C O U R A G I N G U S
T O C O N S U M E E N E R G Y-
D E N S E F O O D A N D D R I N K S
A C T I VI T Y
G O E S D O WN . . .
8 | BIG PICTURE 1
RIGHT
M A N Y F A C T O R S A R E
C A U S I N G U S T O L E A D
L E S S A C T I VE L I VE S A N D
TA K E I N T O O M U C H
E N E R G Y.
C o m p u te r
g a m e s. . .
C a r c u ltu re . . .
L a b o u r-sa vin g
d e vic e s. . .
B u sy live s. . . F izzy d rin k s. . .
F a st fo o d . . .
E n e rg y-ric h
fo o d . . .
Te le visio n . . . L e ss P E . .
JANUARY 2005 | 9
Is obesity only a problem in the rich Western world? Absolutely not. F in d o u t
a b o u t th e im p a c t o f o b e sity in th e d e ve lo p in g wo rld a t B ig P ic tu re O n lin e
www. we llc o m e . a c . u k /b ig p ic tu re /o b e sity
P syc h o lo g ic a l fa c to rs u n d o u b te d ly
in u e n c e e a tin g a n d e x e rc ise h a b its,
a n d h e n c e we ig h t.
E a tin g is n o t o n ly n e c e ssa ry b u t
e n jo ya b le . R e se a rc h h a s sh o wn th a t
e a tin g c a rb o h yd ra te s b o o sts le ve ls o f
se ro to n in a n d e n d o rp h in s in th e b ra in ,
p ro d u c in g fe e lin g s o f p le a su re . T h e se
a re p a rt o f reward pathways in th e
b ra in th a t e n c o u ra g e u s to d o th in g s
th a t we h a ve g a in e d fro m in th e p a st.
T h e re wa rd p a th wa ys m a y d rive u s
to o n e c o u rse o f a c tio n , b u t we a lso
h a ve b ra in syste m s th a t c a n o ve r-rid e
th e m . T h e se in c lu d e sig n a ls fro m
th e th in k in g a re a s o f th e b ra in , th e
frontal cortex. S o we c a n d e la y a
fe e lin g o f re wa rd in fa vo u r o f a
lo n g e r-te rm g o a l. T h is p syc h o lo g ic a l
m e c h a n ism is k n o wn a s delayed
gratication . We m a y sa ve n o w in
o rd e r to e n jo y a re la x e d re tire m e n t.
B u t it a p p e a rs th a t we a re n o t a c tu a lly
ve ry g o o d a t d e la ye d g ra ti c a tio n .
I n e x p e rim e n ts in wh ic h su b je c ts a re
o ffe re d a re wa rd im m e d ia te ly o r a
b ig g e r re wa rd la te r, m o st p e o p le g o
fo r th e im m e d ia te b e n e t. We a re ,
p e rh a p s, n o t a s lo g ic a l in o u r d e c isio n
m a k in g a s we m ig h t th in k . F o rg o in g
a c re a m c a k e in o rd e r to b e slim la te r
m a y n o t b e in o u r m a k e u p .
R e se a rc h a lso su g g e sts socio-
economic factors a re im p o rta n t.
I n th e U K , wo m e n fro m th e p o o re st
a re a s n o w h a ve a lm o st twic e th e risk
o f o b e sity a s wo m e n in ric h e st g ro u p s.
S o m e so c ia l sc ie n tists su g g e st th a t
fa m ilie s in h ig h e r so c io -e c o n o m ic
g ro u p s h a ve a g re a te r sense of control
o ve r th e ir e n viro n m e n t, wh ic h h e lp s
th e m ta k e lo n g e r-te rm vie ws. T h is
m a y e x te n d to a g re a te r e m p h a sis
o n m a in ta in in g h e a lth , fo r e x a m p le
b y e a tin g m o re b a la n c e d d ie ts.
S u c h vie ws a re su p p o rte d b y a re c e n t
stu d y o f 1 2 0 0 te e n a g e rs in th e n o rth o f
E n g la n d . S tu d e n ts fro m m o re a f u e n t
fa m ilie s h a d th e h ig h e st le ve l o f d ie ta ry
re stra in t, a n d u se d m o re h e a lth y
we ig h t c o n tro l m e th o d s.
T h e le ss we ll o ff, o n th e o th e r h a n d ,
o p t fo r m o re im m e d ia te p le a su re s
p e rh a p s, g ive n th e ir c irc u m sta n c e s,
le ss a b le to im a g in e d ista n t b e n e ts.
T E M P TAT I O N : F A S T F O O D I S E A S Y T O F I N D
I N P O O R A R E A S O F T H E U K .
C O N S U M P T I O N
G O E S U P. . .
EXAMPLES OF
ENERGY USE
1 HOUR OF
THIS ACTIVITY
THIS MUCH
FOOD
*
=
=
=
=
ON THE WEB
GRATIFICATION
Money matters
There is a clear n o rth -so u th d ivid e in life
expectancy in the UK. According to a 2001
analysis by the Ofce of National Statistics,
those who live longest live in the southwest,
southeast and east of England.
There is an in ve rse re la tio n sh ip b e twe e n
p o ve rty a n d life e x p e c ta n c y: the poorer
you are, the sooner you are likely to die.
Obesity is also more common in poorer
parts of the country. This is a strange
reversal it used to be the rich who grew
fat while the poor starved.
R e se a rc h e rs h a ve fo u n d th a t p e o p le o n
lo w in c o m e s e a t th e le a st a m o u n t o f fru it
a n d ve g e ta b le s. Households on lower
incomes consume much more full-fat milk,
soft drinks and more white bread than
wealthier ones. Working class women are
more likely to be obese than those in the
middle or upper classes.
One problem is the availability of fruit and
vegetables. Many poor neighbourhoods
only have small shops, which offer a limited
range of food, sometimes at higher prices
than big supermarkets. Some of Britains
poorest areas are known as re ta il d e se rts
they have so few food shops.
The upshot is that the poorer you are, the
less you get for your money. At the same
time, fast food outlets are cropping up
everywhere. C o n ve n ie n c e fo o d is c h e a p
a n d llin g , a n d c h ild re n lik e it. For a single
parent on a low income, juggling family and
job, the attraction of ready-made meals and
take-away menus is obvious.
The wealthy, by contrast, have the money
to buy healthy food and join health clubs.
And they will probably have friends from a
similar background, with similar ideas about
weight and healthy eating.
With daily life providing less opportunity to
burn calories, p e o p le in c re a sin g ly n e e d to
p la n sp e c i c a lly fo r e x e rc ise something
that generally requires time and money.
=
*Approximately!
F o o d a t
le isu re ve n u e s. . .
M a ss m a rk e tin g . . .
10 | BIG PICTURE 1
Healthy lifestyles
One way to tackle obesity is by promoting h e a lth ie r
life style s. To date, there has been no public health
education campaign directly aimed at reducing obesity
through nutritional changes, or by any other means.
Although campaigns promoting healthy lifestyles are already
in place 30 minutes of physical activity, ve times a
week, and the ve a day fruit and vegetable campaign
they are unlikely to tackle the obesity issue. Campaign
gures show that only just over a third of men, and a
quarter of women, meet the physical activity targets.
With o n e th ird o f a d u lts a n d h a lf o f a ll c h ild re n
p re d ic te d to b e o b e se b y 2 0 2 0 , health education
campaigners are trying to get the importance of a
healthy lifestyle message across early, by targeting
nutrition and physical activity in schools.
But it is still debated how effective public health campaigns
actually are. There is very little evidence that they work.
Shifting peoples behaviour is usually very difcult.
Diets
Dieting is dened as any attempt to achieve or maintain
lower body weight by limiting the amount or manipulating
the type of food eaten.
T h e p ro m o tio n o f d ie ts a n d d ie t p ro d u c ts is b ig
b u sin e ss. In 2002 the annual revenue for the US weight-
loss industry was $39 billion (20 billion). The subsequent
rise in industry prots has been mirrored by rising obesity
rates, suggesting the only pounds being lost are from
the dieters wallet.
C a lo rie c o n tro l lies at the heart of most diets.
Successful diets focus on slow achievable weight loss.
To m a in ta in a lo we r b o d y we ig h t, c h a n g e s in d ie t
a n d life style m u st b e c o n tin u e d in d e n ite ly.
Unfortunately, many diets only focus on short-term
weight loss rather than weight-loss maintenance.
It is also important to diet sensibly, as some diets can
themselves lead to health problems. Obese patients
undergoing medical treatment generally follow calorie-
controlled but balanced diets, which are combined with
other forms of help, such as emotional support and
exercise programmes.
Many diets are successful, but maintaining lower
weight over the long term can be very difcult.
BEATING THE
BULGE
S o lo sin g we ig h t ju st m e a n s e a tin g le ss
a n d e x e rc isin g m o re . S im p le ? F a r fro m it. . .
T O D AT E , T H E R E H A S B E E N N O P U B L I C
H E A LT H E D U C AT I O N C A M P A I G N D I R E C T LY
A I M E D AT R E D U C I N G O B E S I T Y.
SURGICAL INTERVENTIONS
T h e m o st c o m m o n o p e ra tio n is n o w
th e u se o f a n in a ta b le b a n d th a t c a n
b e in se rte d th ro u g h k e yh o le su rg e ry a n d
re stric ts sto m a c h size to 1 5 2 0 m l. E ve n
g re a te r we ig h t lo ss c a n b e a c h ie ve d b y
m o re c o m p le x p ro c e d u re s th a t re stric t
sto m a c h c a p a c ity a n d c h a n g e th e o w
o f fo o d th ro u g h th e in te stin e s.
FAST
FACT
T h e in c re a se
in we ig h t o f
th e a ve ra g e
A m e ric a n fro m
1 9 9 0 to 2 0 0 0
4 .5 kg ) c a u se d
a irc ra ft to b u rn
3 5 0 m illio n
m o re g a llo n s
o f fu e l a t a n
a n n u a l c o st o f
$275 million
p e r ye a r.
O e so p h a g u s
P o u c h
S to m a c h
R e se rvo ir
I n a ta b le
b a n d
S m a ll in te stin e
JANUARY 2005 | 11
Drugs
Theres no such thing as a magic
weight-loss pill. Drugs that do work
have to be taken long term, just
like agents used to control blood
pressure or cholesterol levels.
Weight-lowering prescription drugs
are available in the UK, but, like all
drugs, may have sid e -e ffe c ts that
need to be weighed against their
potential benets.
The two most commonly used are
sib u tra m in e and o rlista t (Xenical).
Sibutramine acts on the brain,
making a person feel full sooner
or for longer, while orlistat reduces
fat absorption in the gut.
T h e y a re o n ly p re sc rib e d to
o b e se p e o p le wh o h a ve fa ile d to
lo se we ig h t a fte r c h a n g in g d ie t
a n d life style . They cant be given
for long, and users need advice on
diet and exercise and regular weight
and blood pressure checks.
Other drugs, or combinations of
drugs, have been used in the USA
in the past but serious side-effects
meant that some of these have now
been withdrawn. C le a rly th e re s a
d e m a n d fo r we ig h t-lo we rin g d ru g s,
and many companies are developing
new ones.
One promising new drug, rim o n a b a n t,
seems both to reduce the craving
for food and help people stop
smoking, by acting on a particular
class of c a n n a b in o id re c e p to rs in
the brain. (These receptors respond
to the psychoactive component of
cannabis, chemicals known as
cannabinoids. It was noticed that
smoking cannabis caused the
munchies, and this led to a search
for drugs that block cannabinoid
receptors and reduce appetite.)
The next few years are likely to see
many more products hit the market,
targeting different points in the
bodys weight control system.
Find out more on pharmacological
approaches at Big Picture Online
(www.wellcome.ac.uk/bigpicture/
obesity).
Going to extremes
T h e d e sire to b e slim m e r h a s le d m a n y to tu rn to
u n o rth o d o x wa ys o f lo sin g we ig h t. The desire to make
money has led many to provide miracle cures.
So-called fa d d ie ts abound. The c a b b a g e -so u p d ie t
and g ra p e fru it d ie t are fairly self-explanatory. Others
come with a supposed medical endorsement. Currently
popular (if controversial) is the A tk in s d ie t, and other low-
carbohydrate diets. While these can work over the short
term, their long-term effectiveness is unclear and there
are concerns about their longer-term impact on health.
As well as diets, so m e wo rrie d p a re n ts se n d th e ir
o ve rwe ig h t c h ild re n to fa t c a m p s, or even join camps
themselves. They hope theyll receive supervision and
motivation that will help them reduce their weight. But
keeping the motivation up once back home can be tough.
L ip o su c tio n , sucking out fat using special surgical
equipment, is a more drastic way to remove excess fat.
But it is a cosmetic procedure that can only remove
fat from under the skin, rather than the more unhealthy
fat within the abdomen. Plastic surgeons only use it
to discard stubborn blocks of fat rather than use it to
substitute for diet and exercise. There is no evidence it
offers long-term health benets.
T h e fa m o u s R o m a n rh e to ric ia n Claudius
Aelian 1 7 0 2 3 5 C E ) d e sc rib e d in h is
Historical Miscellany h o w, in A n c ie n t G re e c e ,
D io n ysiu s, th e ru le r o f H e ra c le a , h a d
b e c o m e so o b e se h e su ffe re d d if c u lty
b re a th in g . A s a c u re , h is d o c to rs p u sh e d
lo n g , th in n e e d le s th ro u g h h is h ip s a n d b e lly
wh ilst h e wa s in a d e e p sle e p . T h e tre a tm e n t
fa ile d : a fte r c h o k in g to d e a th fro m h is
fa t, D io n ysiu s c o u ld h a rd ly b e m o ve d
to h is g ra ve .
A n o th e r c la ssic a l tre a tise , Sushrita Samhita,
p a rt o f tra d itio n a l I n d ia n Ayu rve d ic m e d ic in e ,
d e sc rib e s th e u se o f guggul a ye llo wish
re sin p ro d u c e d b y th e th o rn y m u k u l m yrrh
tre e fo r o b e sity. M o re re c e n tly, tria ls h a ve
sh o wn th a t a n e x tra c t fro m g u g g u l lo we rs
c h o le ste ro l le ve ls.
Gold is a n o th e r c la ssic a l re m e d y with a
lo n g h isto ry. O ve r 5 0 0 0 ye a rs a g o , th e
E g yp tia n s in g e ste d g o ld fo r m e n ta l, b o d ily
a n d sp iritu a l p u ri c a tio n . I n 1 9 6 5 D o c to rs
N ilo C a iro a n d A B rin c k m a n n wro te a
b e st-se llin g wo rk e n title d M a te ria M e d ic a ,
in wh ic h c o llo id a l g o ld m e ta llic g o ld
d ivid e d in to n e p a rtic le s a n d su sp e n d e d
in so lu tio n wa s liste d a s th e n u m b e r o n e
re m e d y a g a in st o b e sity.
DIETING
I n th e 1 8 6 0 s, L o n d o n u n d e rta k e r Willia m
B a n tin g fo u n d h e c o u ld su c c e ssfu lly lo se
we ig h t b y e lim in a tin g su g a r, sta rc h , ro o t
ve g e ta b le s a n d p o rk fro m h is d ie t. H is
b e st-se llin g b o o k , Letter on Corpulence,
u rg e d p e o p le to a d o p t a lo w-c a rb o h yd ra te ,
h ig h -p ro te in d ie t a n d B a n tin g b e c a m e a
p o p u la r we ig h t-lo ss
stra te g y in A m e ric a .
I n 1 8 9 0 , H o ra c e F le tc h e r a d vo c a te d
c h e win g e ve ry m o u th fu l a h u n d re d tim e s
u n til it tu rn e d to liq u id a n d swa llo we d
itse lf . T h is p ro lo n g e d c h e win g b e c a m e
k n o wn a s F le tc h e rizin g a n d F le tc h e r
h im se lf a s th e G re a t M a stic a to r .
J o h n H a rve y K e llo g g , a d e vo te e o f
F le tc h e rizin g , in ve n te d a C h e win g S o n g
fo r p a tro n s a t h is n u tritio n a l sa n a to riu m in
B a ttle C re e k , M ic h ig a n . K e llo g g a lso
p ro m o te d ve g e ta ria n ism a n d , u n su rp risin g ly,
a d ie t ric h in h is o wn in ve n te d c e re a ls.
D r R o b e rt A tk in s in tro d u c e d h is c o n tro ve rsia l
h ig h -p ro te in d ie t in 1 9 7 2 . T h is th e n to o k
a b a c k se a t to a se rie s o f lo w-fa t, h ig h -
c a rb o h yd ra te d ie ts, su c h a s th e D e a n
O rn ish p ro g ra m m e a n d th e P ritik in d ie t,
o ve r th e n e x t th re e d e c a d e s.
T h e m id -1 9 9 0 s sa w th e c a rb o h yd ra te
b a c k la sh , with th e a rriva l o f B a rry S e a rs
T h e Z o n e p la n a n d o th e r su g a r-b u stin g
d ie ts. A n d b y th e e a rly 2 0 0 0 s, A tk in s wa s
b a c k with a ve n g e a n c e .
U ltim a te ly, m o st d ie ts a re sim p ly c a re fu lly
p a c k a g e d wa ys to e n c o u ra g e p e o p le to
e a t le ss, u su a lly b y re stric tin g th e ra n g e
o f fo o d th a t c a n b e e a te n . O n e d ra wb a c k ,
h o we ve r, is th a t b y fo c u sin g th e m in d o n
we ig h t lo ss a n d o n wh a t c a n n o t b e e a te n ,
th e y m a y a c tu a lly m a k e it h a rd e r fo r u s to
re sist te m p ta tio n .
T H E R E S N O S U C H T H I N G
A S A M A G I C
WE I G H T-L O S S P I L L
FAST
FACT
Wim b le d o n s
se a ts a re 6 c m
wid e r th a n
th e o rig in a l
1 9 2 2 m o d e ls.
A POTTED HISTORY
OF ANTI-OBESITY TREATMENTS
12 | BIG PICTURE 1
H o w im p o rta n t is yo u r size to yo u ?
Vicki Swinden Not even slightly. But for 40 years I
spent every waking hour worrying about how I could
lose weight and feeling a failure because I couldnt
control it.
Now Im very careful with the messages I give my
children. I never say, you cant eat that, because if
you restrict someone, they want it even more. The
fridge is 98 per cent full of fresh food, but if we want
(for example) a McDonalds every now and then,
well have it.
Louise Diss M o re im p o rta n t th a n it sh o u ld b e .
I so m e tim e s ju d g e m yse lf m o re o n h o w fa t I fe e l,
re g a rd le ss o f m y a c tu a l size .
H o w d o yo u fe e l o th e rs
p e rc e ive yo u ?
VS On the street, people have been verbally and
physically obscene. Ive been spat at. On the buses
and tube people say dont sit next to me. In the
supermarkets, they say, you shouldnt have that in
your shopping basket, thats why youre so fat.
The Fat is the New Black website has had enormous
response. Some has been good some horrendous.
People feel its OK to write to me and call me greedy,
disgusting, ugly, lazy, and a drain on the NHS. After
my last Radio 2 interview, I got an email from a girl
on the point of suicide. People want to die because
of the pressure our nation puts on them.
LD A s a n a d u lt I wa s in tim id a te d b y
g ro u p s o f te e n a g e k id s, wh o sa id th in g s
lik e , F a t b itc h , wh a t d o yo u th in k yo u re
d o in g o n th is sid e o f th e stre e t?
O n e p a rtic u la r g ro u p th re w sto n e s a t
m y win d o w. I h a d to te ll th e p o lic e in
th e e n d a n d th e y we re c a u tio n e d .
REAL VOICES
Wh a t s it re a lly lik e to b e o b e se ?
We sp o k e to two p e o p le with e x p e rie n c e
Vic k i S win d e n , wh o ru n s a size a c c e p ta n c e g ro u p ,
a n d L o u ise D iss, wh o h a s stru g g le d with h e r
we ig h t fo r m a n y ye a rs.
D o yo u wo rry a b o u t yo u r fu tu re
h e a lth ? Wh a t d o yo u th in k th e
risk s a re ?
VS No, I think Im in the best shape ever and Im
improving by the day. I feel very positive about my
future health. I eat a very healthy diet and take lots
of exercise.
LD I d o wo rry. I wa n t to b e h e a lth y wh e n
I m o ld . I e sp e c ia lly wo rry a b o u t m y b o n e s g o in g
a n d g e ttin g a rth ritis in m y k n e e s.
H o w m u c h p re ssu re d o yo u fe e l to
b e a p a rtic u la r size a n d sh a p e ?
VS The advertised world puts pressure on us all
to conform to a certain ideal.
LD I h a ve a h u sb a n d a n d two c h ild re n wh o lo ve
m e fo r wh o I a m . B u t p e o p le d o fe e l a b le to
c o m m e n t. A t c o lle g e I o n c e b o u g h t c h ip s a n d a
stu d e n t o n m y c o u rse , sa id , Yo u re n o t g o in g to
e a t th o se a re yo u ? A fte r I lo st we ig h t, so m e o n e
e lse sa id , Yo u re m o re c re d ib le n o w . I n d th a t
a m a zin g I m still th e sa m e p e rso n !
LD R e se a rc h sh o ws th a t p e o p le th in k
o b e se p e o p le a re le ss in te llig e n t:
th e y re o fte n p o rtra ye d a s b u ffo o n s
in lm s a n d p la ys. T h e y re n e ve r
p o rtra ye d a s th e se x g o d d e ss.
H O W D O YO U T H I N K
S O C I E T Y T R E AT S /VI E WS T H E
O VE R WE I G H T A N D O B E S E ?
M O N T Y P YT H O N S
M R C R E O S O T E :
P O R T R AYE D A S A
G L U T T O N U N A B L E
T O C O N T R O L
H I S E AT I N G ,
H E E VE N T U A L LY
E XP L O D E S .
Kobal Collection
JANUARY 2005 | 13
D o yo u d ie t? Wh a t d ie ts h a ve yo u
trie d ? D id th e y wo rk ?
VS I have tried every diet on the market including
slimming pills, food substitutes and meal replacements
they all work and on one I lost pounds in weight.
Never once has the weight loss been maintained and
I believe this is because the whole picture was not
being dealt with. My dieting is more advantageous to
the Diet Industry than it is to me.
LD O ve r th e ye a rs I ve trie d e ve ryth in g , in c lu d in g
th e c a b b a g e so u p d ie t, h a rd -b o ile d e g g d ie t,
slim m in g g u m c o n ta in in g a m p h e ta m in e s a n d
m e a l re p la c e m e n ts.
T h e y a ll c o n c e n tra te d o n th e wro n g th in g fo o d .
B u t fo o d isn t th e issu e . T h e b e st d ie t is to lo o k
a t wh a t s g o in g o n p syc h o lo g ic a lly. O n e d a y it
c lic k e d th a t I wa sn t ta k in g c a re o f m yse lf. I f I fe lt
lo w if I wa lk e d p a st a g ro u p o f te e n a g e rs a n d
th e y sa id so m e th in g th e n I wo u ld b u y a c re a m
b u n to fe e l b e tte r.
To b re a k th a t c yc le I n e e d e d to lo o k a t m y wh o le
se lf m in d , b o d y, wo rk , h o m e a n d n d a le ve l
o f c o n te n tm e n t th a t d id n t in vo lve fo o d . O n c e I d id
th a t I wa s a b le to lo se six sto n e a n d k e e p it o ff.
Wh a t d o yo u th in k sh o u ld
b e d o n e a b o u t it, if a n yth in g ?
VS I nd the debate going on now very scary.
Were telling obese people that theyre wasting
NHS time and resources. They already feel unworthy
now they feel they cant go to their GP. I cant see
the problem getting better, if thats the way its dealt
with. People dont work well if theyre criticised:
they need encouragement, congratulations and
positive feedback.
LD I t s to o b ig a p ro b le m fo r a q u ic k a n swe r.
S e n sib le fo o d s sh o u ld b e a d ve rtise d a n d so ld
a t th e m o m e n t yo u c a n a d ve rtise c h o c o la te
a lth o u g h yo u c a n t a d ve rtise c ig a re tte s) . P e o p le
sh o u ld b e h e lp e d to g e t th e ir we ig h t d o wn in
a h e a lth y wa y. We n e e d to a im fo r a n a tio n o f
p e o p le wh o a re a b le to n o t re ly o n fo o d , d ru g s
a n d a lc o h o l to fu l l a n e e d .
Wh y d o yo u th in k yo u a re th e sh a p e
yo u a re ? D o yo u th in k it is writte n
in yo u r g e n e s? O r yo u r m e ta b o lism ?
VS There are denitely genetic factors. My mother
and grandmother were big, they have the same hair
and skin as me I was never going to be 8 stone.
There are also psychological factors. When I was
four years old, someone commented to my mum
that I was fat and she started monitoring my food.
I dont blame her, she tried to do what was right.
LD I d o n t th in k it s m y g e n e s. I h a ve se ve n
b ro th e rs a n d siste rs, so m e o f th e m a re o ve rwe ig h t,
b u t I a m th e o n ly o n e wh o h a s b e e n g ro ssly
o ve rwe ig h t.
I th in k a lo t is e n viro n m e n ta l. I g re w u p o n a fa rm ,
wh e re th e re wa s lo ts o f p h ysic a l wo rk lik e p o ta to
p ic k in g to b e d o n e . I wa s a lso a c o u n ty swim m e r,
so I wa s ve ry t. Wh e n I le ft h o m e I h a d a n
in a c tive jo b , a n d b e c a u se I wa s o n a lo w in c o m e ,
I a te c h e a p fo o d lik e c h o c o la te , wh ic h p ro vid e d
a q u ic k x a n d th e p o u n d s g ra d u a lly p ile d o n .
Wh o d o yo u th in k sh o u ld
ta k e re sp o n sib ility?
VS All of us, man, woman, child, local and national
governments and the media.
LD A d u lts n e e d to ta k e re sp o n sib ility fo r
th e m se lve s. Wh e n it c o m e s to c h ild re n , p a re n ts,
th e g o ve rn m e n t, th e fo o d in d u stry a n d m a rk e tin g
n e e d to ta k e re sp o n sib ility.
Vic k i S win d e n ru n s F a t is th e N e w B la c k , a
size a c c e p ta n c e g ro u p wh ic h sh e fo u n d e d to
c o u n te r th e p u b lic s n e g a tive a ttitu d e to wa rd s
o b e se p e o p le .
www.fatisthenewblack.com
L o u ise D iss is a so c ia l wo rk e r a n d a n o b e sity
c o u n se llo r fo r T h e O b e sity Awa re n e ss a n d
S o lu tio n s Tru st T O A S T ) . T O A S T is a n a tio n a l
c h a rity d e d ic a te d to e n c o u ra g in g a b e tte r
u n d e rsta n d in g o f o b e sity, its c a u se s a n d th e
p ra c tic a l so lu tio n s th a t a re o r sh o u ld b e a va ila b le .
www.toast-uk.org.uk
H O W C O M F O R TA B L E A R E YO U WI T H
YO U R C U R R E N T S I Z E ? WO U L D YO U
P R E F E R T O B E S L I M M E R ?
VS A friend whod had an implant
in her stomach to stop her eating,
offered to pay for me to have the
same surgery (the operation costs
several thousand pounds). I said, No,
I dont want it in a million years. One,
its invasive. Two, its not a priority.
VS I dont know. Its used as too much
of a catch-all word.
LD Ye s. I t s o n e o f th e b ig g e st
d ise a se s o f th e la st fe w d e c a d e s
a n d g e ttin g b ig g e r. I t s a n e p id e m ic .
D O YO U C O N S I D E R
O B E S I T Y T O B E A D I S E A S E ?
14 | BIG PICTURE 1
WHOSE
RESPONSIBILITY?
I f we a re g o in g to h a lt th e tre n d to wa rd s o b e sity,
so m e th in g n e e d s to c h a n g e . I s it ju st u p to u s to
lo o k a fte r o u rse lve s b e tte r, o r d o o th e rs n e e d to
ta k e re sp o n sib ility to m a k e it h a p p e n ?
I n d ivid u a ls
Is weight control just up to
us and our will power?
We may instinctively feel that a
persons lifestyle is a matter of
personal choice. But:
Te m p ta tio n : Cheap, widely
available food.
L ife p re ssu re s: Too busy to eat
properly or exercise.
A g e n e tic le g a c y: Strong
evolutionary pressures drive
us to eat for survival.
Whatever the causes, it appears that
relying on individual self-restraint is
not an effective strategy for a healthy
population.
P a re n ts
Shouldnt parents take
the lead?
One US doctor described the surge
in childhood obesity as child abuse.
Surveys in the USA and UK indicate
that people think parents have the
primary responsibility for their childrens
diet. So what is going wrong?
Te m p ta tio n : Youngsters are faced
with many opportunities to indulge.
I m m a tu rity: A childs brain is
also less able to imagine, or be
inuenced by, the consequences
of their actions so will be less
deterred by fears of future health
problems.
P e ste r p o we r: Constant pressure
on parents.
Many have argued that marketing of
fattening products to children should
be minimised or banned, to provide
support for parents.
S c h o o ls/e d u c a tio n
Is obesity an issue
for schools?
Schools have a duty of care to
protect and support young people.
They can help children choose
health, encouraging sensible eating
and exercise.
H e a lth y e a tin g sc h e m e s: More
balanced school lunches; fruit
tuck-shops, breakfast clubs, and
the inclusion of healthy snacks and
bottled water, alongside chocolate,
in school vending machines.
Te a c h in g : About the nutritional
content of food, plus planning and
preparing healthy meals.
A c tivity: Some schools have
extended the school day in order to
accommodate the Governments
recommended two hours of
physical activity a week plan.
S p o rt: Aerobics and swimming
may help pupils put off by
traditional team games to nd a
form of physical activity they enjoy.
? ? ?
THE STATE WERE IN
H o w b ig a ro le d o we wa n t th e sta te
to p la y in o u r live s? T h is is a d e e p ly
p o litic a l issu e : so m e wo u ld a rg u e
fo r little p o litic a l in te rve n tio n in
b u sin e ss o r p e o p le s p e rso n a l live s;
o th e rs wo u ld se e th e sta te ta k in g a
m o re a c tive ro le .
Wh e n d e c isio n s im p a c t so d ire c tly
o n p e o p le s c h o ic e s, re g u la tio n c a n
se e m to b e d e n yin g u s fre e d o m s.
S o m e ta lk in te rm s o f a nanny
state wh e re th e re is a h ig h
d e g re e o f g o ve rn m e n t in te rve n tio n ,
b e c a u se th e sta te th e n a n n y )
k n o ws b e st.
DO WE WANT ONE?
A p p a re n tly we d o . A c c o rd in g to a
re c e n t su rve y b y th e K in g s F u n d ,
th re e q u a rte rs o f p e o p le in th e U K
wa n t stric te r le g isla tio n to p re ve n t
p e o p le fro m sm o k in g a n d e a tin g
u n h e a lth ily. T h is c o u ld m e a n la ws
to b a n sm o k in g in p u b lic p la c e s,
o r fat taxes .
B u t we wa n t th e b e st o f b o th
wo rld s. S u rve ys sh o w th a t wh ile
we su p p o rt le g isla tio n in th e o ry,
we o fte n o p p o se it wh e n it im p a c ts
o n o u r o wn live s. We a rg u e fo r
civil liberties a n d p e rso n a l rig h ts .
We re se n t g o ve rn m e n ts p o k in g
th e ir n o se s in to o u r b u sin e ss.
DAMNED IF YOU DO...
O n th e o th e r h a n d , if th e
g o ve rn m e n t fa ils to a c t, th is le a ve s
c h ild re n e x p o se d to e x p lo ita tive
FAST
FACT
N e a rly
6 tim e s
a s m a n y
F ilip in o
wo m e n a re
o ve rwe ig h t
a n d o b e se
to d a y a s th e y
we re 2 0 ye a rs
a g o u p fro m
6 p e r c e n t to
3 5 p e r c e n t) .
G
e
t
t
y
K
o
b
a
l

C
o
l
l
e
c
t
i
o
n
R
e
x

F
e
a
t
u
r
e
s
JANUARY 2005 | 15
I n d u stry
Should the food industry
show more concern?
The food industry spent 727 million
advertising food, soft drinks and
chain restaurants in 2003 more
than 60 times the entire annual budget
of the NHS Health Development
Agency. Is this where action
is needed?
R e g u la tio n : The industry resists
attempts at greater regulation,
arguing that adults can make their
own decisions about what they
eat and that sedentary lifestyles
are the main problem.
C h a n g in g p ra c tic e : McDonalds
has phased out its Supersize
meals in the USA, and is beginning
to offer healthier options. One
sweet maker has announced the
end of the king-size chocolate
bar (though only by dividing it into
two bars).
C h ild re n : The industry says
advertising is designed to increase
brand loyalty, not increase
consumption.
Ta c tic s: Some observers have
criticised the industrys political
lobbying activities, to inuence
government policies and the
recommendations of bodies such
as the World Health Organisation.
The Food Standards Agency has
called upon the food industry to
work collaboratively to recognise the
public health impact of the products
it sells, and to consider what it could
do to address it.
G o ve rn m e n t
Is the problem serious enough
for Government action?
Obesity is now considered a public
health problem. As well as harming
many individuals, it has economic
consequences (time off work, sick
pay, healthcare costs). The House
of Commons Health Committee
called for action in two areas:
Lower calorie intake:
F o o d la b e llin g : To show clearly
whether food is high or low in
calories.
F o o d a d ve rtisin g : A restriction
on advertising aimed at children.
F a t ta x : On high-calorie foods.
Physical activity:
U rb a n p la n n in g : To support
pedestrians.
S p o rt: Promotion of sporting
activities.
? ?
a d ve rtisin g a n d e a sy a c c e ss to
u n h e a lth y fo o d s. S h o u ld n t we
p ro te c t th e vu ln e ra b le ?
A n d o b e sity is n o t ju st a p e rso n a l
issu e . I t is n o w a lso a public health
problem. O b e sity-re la te d illn e ss
so a k s u p h e a lth c a re re so u rc e s
th a t c o u ld b e u se d e lse wh e re .
D o e s th is ju stify g o ve rn m e n t
in te rfe re n c e in o u r d a ily live s?
P u n ish m e n ts o r in c e n tive s?
E d u c a tio n o r c o e rc io n ?
H a n d s u p wh o c a n sa y n o to p izza , p u d d in g ,
c h ip s o r c h e e se c a k e . F e w o f u s c a n g e n u in e ly
re sist th e m , ye t if yo u th in k a b o u t it, th e se
fo o d s a re wh o lly u n n a tu ra l. S o wh y a re we so
a ttra c te d to th e m ?
P e rh a p s th e a n swe r lie s with o u r h u n te r-
g a th e re r a n c e sto rs. T h e ir d ie t wo u ld h a ve b e e n
m o stly b ro u s wild ve g e ta b le s, n u ts a n d fru its.
O c c a sio n a lly, th e y wo u ld h a ve fe a ste d o n wo o lly
m a m m o th m e a t, b iso n b o n e m a rro w, a n d wild
fo wl. T h e re wa s p le n ty o f p ro te in a n d fa t in th e ir
d ie ts b u t a lwa ys with h e fty d o se s o f b re fro m
fru it a n d ro o ts.
O u r m o d e rn d ie t is p a c k e d fu ll o f c a rb o h yd ra te s
la rg e ly fro m p ro c e sse d c e re a ls a n d re n e d
su g a r. F ro m th e e vo lu tio n a ry p e rsp e c tive , th is
typ e o f fo o d is re la tive ly n e w. C a rb o h yd ra te s
fro m g ra in s a n d c e re a ls c a m e in a ro u n d 1 2 0 0 0
ye a rs a g o wh e n a g ric u ltu re a n d fa rm in g b e g a n .
A s we ll a s th is ric h h a rve st, a g ric u ltu ra l
b re e d in g a n d in te n sive re a rin g p ra c tic e s h a ve
g ive n u s g re a tly in c re a se d a c c e ss to m e a t.
H u m a n so c ie ty h a s c h a n g e d with e x tra o rd in a ry
sp e e d b u t o u r g e n e s a re m o re o r le ss th e sa m e
a s th o se we h a d wh e n we tro d th e A fric a n
sa va n n a h . S o so m e a rg u e th a t we a re a d a p te d
to a d ie t with p le n ty o f m e a t fa t, lo w in
c a rb o h yd ra te s, a n d g e n e ro u s h e lp in g s o f
se e d s, fru it a n d ve g e ta b le s.
A s a re su lt, we will a lwa ys stru g g le a g a in st th e
a ttra c tio n o f h ig h -c a lo rie fo o d s. I t is o u r g e n e tic
le g a c y. F o r h u n te r-g a th e re rs, re a lity wa s o fte n
g rim : fo o d wa s n o t a lwa ys a b u n d a n t, th e y
swu n g fro m fe a st to fa m in e . A s a re su lt,
h u m a n s wo u ld h a ve e vo lve d to c ra ve e n e rg y-
ric h fo o d s, wh ic h th e y c o u ld sto re in th e ir b o d ie s
a s fa t a s a life in su ra n c e fo r tim e s o f fo o d
sh o rta g e s.
Ye t we n o w live in a so c ie ty wh e re fo o d is
p le n tifu l. T h is is a tim e o f b ig fo o d a n d little
e x e rc ise a life style th a t is a t o d d s with o u r
g e n e tic le g a c y.
HUNTER-
GATHERER
GENES?
Is obesity a disease? Who says so? And when does it become a public
health as well as a personal issue? E x p lo re th e issu e s a t B ig P ic tu re O n lin e
www. we llc o m e . a c . u k /b ig p ic tu re /o b e sity
ON THE W
EB
R
e
x

F
e
a
t
u
r
e
s
S
P
L
16 | BIG PICTURE 1 JANUARY 2005
We are living a highly o b e so g e n ic environment:
energy-rich food is cheap, plentiful and highly
palatable; modern lifestyles require little energy
expenditure.
Huge amounts of money are spent a d ve rtisin g
and promoting energy-rich products.
Overweight people suffer ste re o typ in g and are
widely discriminated against; this may cause
emotional distress and comfort eating.
We ig h t-lo ss c o u rse s can work, when calorie-
controlled diets are combined with exercise
programmes, behavioural advice, and emotional
support.
P h a rm a c e u tic a l a n d /o r su rg ic a l a p p ro a c h e s
are available when dietary/exercise
approaches are not working, but they
may have serious side-effects.
OBESITY:
THE BIG PICTURE
Obesity is a growing p e rso n a l a n d p u b lic h e a lth
p ro b le m in wealthy countries, and increasingly in
developing nations.
Obesity is linked to a number of d ise a se s, such
as increased risk of diabetes, heart disease and
cancer.
There is disagreement about the fu ll e x te n t of the
health impact of obesity; some effects may be due
to u n tn e ss rather than obesity itself.
Weight gain arises when the a m o u n t o f e n e rg y
taken in as food is greater than the amount burned
off by activity and the bodys metabolism.
Body weight is inuenced by a wid e ra n g e of
genetic, metabolic, prenatal, psychological and
environmental factors.
A network of c h e c k s a n d b a la n c e s involving our
hormonal and nervous systems attempts to keep
our weight within a relatively narrow range.
Weight loss usually triggers mechanisms that
p ro m o te a d d itio n a l fo o d in ta k e and weight gain.
Additionally, teachers can order
a class set of two copies or more
for students.
Order sets of a specic issue
or subscribe to receive copies
of each issue until further notice.
Order 10 or more copies and
receive an additional poster
specic to this issue.
C la ss-se t p ric e s
220 copies: 1.00 per copy
per issue (inc. P&P in the UK)
>20 copies: 0.75 per copy
per issue (inc. P&P in the UK)
P o sta g e a n d p a c k in g c h a rg e s
UK free of charge
EU 0.15 extra per copy ordered
Rest of world 0.30 extra
per copy ordered
Other interested groups can also
order copies at these prices.
P a ym e n t m e th o d s
We accept cheques, and all major
credit cards and debit cards.
C o n ta c t
See www.wellcome.ac.uk/bigpicture
for full details, or:
T +44 (0)20 7611 8651
E publishing@wellcome.ac.uk
Or write to:
Big Picture series
The Wellcome Trust
FREEPOST
ANG 6754
Ely CB7 4YE.
LabNotes re c ip ie n ts
If you previously received a copy
of LabNotes you will continue to
get a single free copy of each issue
in the Big Picture series.
L ik e its p re d e c e sso r, LabNotes, in d ivid u a l
c o p ie s o f e a c h issu e in th e Big Picture se rie s a re
a va ila b le fre e fo r te a c h e rs a n d o th e r e d u c a tio n
p ro fe ssio n a ls, o r a n yo n e with a p ro fe ssio n a l
in te re st in th e to p ic .
To order an individual copy of a specic issue,
or subscribe to receive a copy of each issue in
the series, sign up at
www. we llc o m e . a c . u k /b ig p ic tu re /o rd e r.
BIG PICTURE SUBSCRIPTIONS