2. Overweight and its threat to public health

While multiple factors contribute to a person’s weight, it is widely recognised that changes in body-mass index (BMI) are due to an imbalance between energy intake from diet and energy output through physical activity. For reasons discussed below, environments in which people live are increasingly considered “obesogenic” given they encourage people to eat more and move less (Swinburn, Egger and Raza, 1999[1]).

A multitude of factors has altered what and how much people eat. Advances in technology, globalisation, the expansion of food retail, rising incomes and urbanisation have changed the quantity and quality of calories consumed (Etilé and Oberlander, 2019[2]; Baker et al., 2020[3]). For example, today, mass-produced, ultra-processed foods (UPFs) are both cheap and readily accessible in countries across the world. As a result, among high-income countries, UPFs now make up “30-60% of total dietary energy consumed”. Further, these aforementioned factors have contributed to the rise of “food swamps” characterised by areas with a high number of fast food outlets (OECD, 2021[4]).

Among OECD countries, the quantity of calories has increased, while the nutritional quality has worsened. Between 1961 and 2013, total food supply grew by 10% among OECD countries – or from 3 000 to 3 300 calories per capita, per day. EU27 countries recorded similar levels of growth (OECD, 2019[5]). Examining changes in calories alone is insufficient, given the quality of calories plays a key role in weight gain/loss. Today, consumption of nutrients associated with weight gain such as added fats and sugars, as well as saturated fat intake, primarily from animal sources, play a larger role in diets among OECD countries (WHO and FAO, 2003[6]). This comes at the expense of foods with healthy dietary elements such as fruit and vegetables and whole grain products, whose consumption is associated with weight loss. For example, over half of all adolescents do not consume fruit or vegetables each day (Figure 2.1), with similar figures recorded for adults. Further, UPFs, which are linked to higher calorie intake and worse health outcomes (Hall et al., 2019[7]) comprise over 50% of total energy intake in countries such as the United States and the United Kingdom (Marino et al., 2021[8]).

Physical activity is another key determinant of overweight.1 There are four areas where people are physically active throughout the day – at work or school, at home, during leisure time and when travelling (see Table 2.1). When combined, these four types of physical activity become the second largest contributor to total energy expenditure behind resting metabolic heart rate, (the rate at which your body burns energy when at complete rest) and before the thermic effect of feeding (energy used to digest and process food) (FAO, 2003[10]). Of the three contributors to energy expenditure, physical activity is the most modifiable and therefore a key policy area for promoting weight loss.

The benefits of physical activity extend beyond weight loss and management. Key benefits include an improvement in mental health, strengthening of bones, muscles and joints, as well as lowering the risk of illness (e.g. cardiovascular diseases, some commonly occurring cancers, Alzheimer’s disease, dementia, high blood pressure, and type 2 diabetes).

People today have fewer reasons to be physically active. Approximately a third of all adults in the OECD and EU are insufficiently active with figures ranging from just under 20% in Finland to up to 46% in Portugal. For all countries, levels of insufficient physical activity are higher for women than men (Figure 2.2). Low levels of physical activity reflect factors such as advances in technologies and changes to the built environment, which have given people fewer reasons to be physically active. For example, between 1990 and 2019, the number of passenger cars per 1 000 people – also known as the motorisation rate – grew by 88% among EU27 countries (Eurostat, 2019[12]). Further, as of 2019, cars are the predominant form of urban transport in the EU, which may in part reflect higher levels of car ownership (Eurostat, 2021[13]). Conversely, there is scientific consensus that people who live in “walkable” environments are more likely to have higher levels of physical activity (Mackett and Brown, 2011[14]). (Further details on physical activity trends and patterns are available in an upcoming joint OECD and WHO publication (forthcoming[15])).

Levels of sedentary behaviour are also high. Similar to physical activity, sedentary behaviour is another key determinant of total energy expenditure and is therefore important to examine when discussing trends in overweight and obesity. Sedentary behaviour is defined as any behaviour when awake, which involves low energy expenditure (i.e. 1.5 metabolic equivalent of task (MET)2 or lower) such as sitting, reclining or in a lying posture (van der Ploeg and Hillsdon, 2017[17]). Levels of sedentary behaviour are high among OECD countries for a variety of reasons including the proliferation of labour-saving technologies, such as laptops (see Box 2.1). For example, nearly four in ten adults across the EU complete their work while sitting down, with figures as high as 54% in the Netherlands (Eurostat, 2017[18]). Further, in the United States, the average civilian worker sits for 43% of the workday (U.S. Bureau of Labor Statistics, 2020[19]). During the COVID-19 pandemic, there is consensus among published papers that levels of sedentary behaviour worsened, for example due to an increase in daily screen time (OECD and WHO, forthcoming[15]).

There is growing recognition that changes to the food and physical environment are not solely responsible for rising rates of overweight. Other modifiable risk factors that contribute to a person’s weight gain/loss include stress levels, sleep and the gut microbiota:

  • Sleep: sleep deprivation can affect a person’s energy intake/output through several channels including increasing hunger, allowing people more time to eat and decreasing levels of physical activity due to fatigue. Several studies are now available measuring the link between sleep and weight in both children and adults. Among young people, a meta-analysis suggest there is an association between poor sleep quality and overweight and obesity (e.g. young adults who experience inadequate sleep are 27% more likely to live with overweight) (Fatima, Doi and Mamun, 2016[24]). Similarly for adults, a recent systematic review and meta-analysis concluded there is a significant association between short sleep duration and risk of future obesity (Bacaro et al., 2020[25]).

  • Stress: stress due to work, personal or financial strain can negatively impact a person’s energy intake/output leading to weight gain, for example, due to “euroendocrine and inflammatory pathways that directly increase abdominal adiposity” as well as a preference for high energy foods (Harding et al., 2013[26]). A longitudinal study of over 5 000 Australian adults found those with perceived high levels of stress experienced a 0.20kg/m2 greater gain in BMI compared to those with low stress levels (Harding et al., 2013[26]).

  • Gut microbiota: microbiota plays a key function within the human body, for example, by regulating the immune system, food digestion and production of key vitamins. A diverse gut microbiota consisting of different types of microorganisms (e.g. bacteria and fungi) is considered healthy and is largely influenced by a person’s diet. For example, there is emerging evidence indicating an association between a gut microbiota with reduced diversity3 and obesity (Kim et al., 2020[27]). People can create more diverse gut microbiota by consuming a diet rich in a variety of fruits, vegetables, legumes, nuts, seeds and whole grains. Further, there is evidence to show that a plant-based diet is also good for the environment (see Box 2.2).

Rates of overweight and obesity for both adults and adolescents have been rising and are higher for men. Between 1996 and 2016, the proportion of men and women in the OECD living with obesity increased by 10 and 7 percentage points, respectively (WHO, 2016[30]). Consequently, as of 2016, nearly one in four adults in the OECD live with obesity. Over the same period (1996-2016), the proportion of children aged between five and nine considered overweight increased from 21% to 31% (OECD, 2019[31]). More recent estimates (2019) from a smaller number of countries that report measured data suggest rates of overweight, which includes obesity, are even higher at around 64% and 56% of men and women in the OECD, respectively (see Figure 2.3).

Overweight is more prevalent among lower socio-economic groups. As previously discussed, people increasingly live in obesogenic environments. Individuals with a higher socio-economic status (SES) are better equipped to live in such an environment – for example, higher educated individuals may have a better understanding of what constitutes a healthy lifestyle and the resources to pursue this way of life (Devaux et al., 2011[32]; Placzek, 2021[33]). Data from the Health Behaviour in School-aged Children (HBSC) survey 2017/18 reflect this theory with 26% of 15-year-olds with a low family affluence status (FAS) report being overweight compared to 16% among those with a high FAS (Figure 2.4) (Inchley et al., 2020[9]).

Overweight in adults worsens health outcomes and shortens life expectancy. Adults who live with overweight are at greater risk of developing non-communicable diseases (NCDs) including type 2 diabetes, several cancers, stroke, and asthma (Nyberg et al., 2018[34]). Modelling work undertaken by OECD across 52 countries4 estimates that between years 2020 and 2050, overweight and obesity will cause an additional 462 million cases of cardiovascular disease (CVD) and 212 million new cases of diabetes. Respectively, these figures represent 18% and 58% of all new cases (OECD, 2019[5]). In turn, higher incidence of NCDs causes premature mortality and therefore a decline in overall life expectancy (LE): over the same period (2020-50), overweight and obesity is estimated to reduce average LE in the OECD by 2.7 years, with this figure increasing to 3.2 years when considering healthy life years (HALE) (OECD, 2019[5]) (Figure 2.5).

Negative health effects associated with excessive weight also occur during early years of life. Overweight in childhood is a key determinant of obesity in adulthood, which, as previously mentioned, is associated with a range of NCDs. Children living with overweight may also experience health issues at an early age including breathing difficulties, insulin resistance and hypertension. Overweight at a young age can also cause higher levels of mental distress, for example, due to bullying: OECD analysis found boys aged 11-15 living with obesity are nearly twice as likely to be bullied when compared to their normal weight peers, with this figure increasing to three times as likely for girls (OECD, 2019[5]).

Overweight has a direct impact on health expenditure by increasing demand for health care services. People with overweight are more likely to develop one or multiple NCDs. Consequently demand for health care services that treat and manage NCDs rises. Not only does overweight increase the frequency of contact with the health care system, it also increases the cost per contact as treatment is often more complex (Bertakis and Azari, 2005[35]). OECD analysis estimates that treating overweight and its related conditions cost countries, on average, an additional USD PPP (purchasing power parity) 209 annually per capita, which translates into 8.4% of total health expenditure (Figure 2.6).

Overweight has an indirect negative impact on economic outcomes by depressing workforce productivity. Overweight and its related health issues reduce productivity among working-age adults, for example, through absenteeism and early retirement. Across OECD countries, overweight is estimated to reduce workforce productivity, on average, by -1.66% per capita, per year. When combining the impact on the workforce and life expectancy, overweight is estimated to reduce GDP by 3.3% per year on average across OECD countries.

People living with overweight, and obesity in particular, are at greater risk of developing severe symptoms and dying from COVID-19. For example, a study by Tartof et al. (2020[36]) using data from a United States integrated health care organisation, found compared to patients with a “normal weight” (BMI between 18.5-24 kg/m2), morbidly obese patients are between 2.68 (BMI 40-44 kg/m2) and 4.18 (BMI > 45 kg/m2) times more likely to die from COVID-19. Similarly, several studies show that obesity increases the risk of developing severe COVID-19 symptoms as measured by hospitalisations, including intensive care unit admissions (CDC, n.d.[37]; Public Health England, 2020[38]; Yang, Hu and Zhu, 2020[39]; the LICORN and the Lille COVID‐19 and Obesity study group, 2020[40]; Popkin et al., 2020[41]; World Obesity Federation, 2021[42]).

The COVID-19 pandemic had a negative impact on lifestyle behaviours resulting in weight gain. OECD countries responded to the COVID-19 pandemic by introducing “lockdowns” as a way to reduce disease transmission. This significantly altered people’s daily lives including how they eat and exercise. It is too soon to conclude what long-term impact the pandemic had on peoples weight, however, studies on short-term weight gain/loss as well as overweight risk factors are available. For example, results from an Ipsos survey covering 19 OECD countries found that in all countries, the proportion of the population who reported gaining weight during the pandemic was greater than those reporting losing weight (Figure 2.7) (Bailey et al., 2021[43]). A summary of studies looking at the impact of COVID-19 on overweight risk factors is available in Box 2.3.

Overweight is a top political priority in the OECD given its detrimental impact on health and economic outcomes. Overweight causes health expenditure to rise and productivity in the workforce to lower. Given the wide-reaching impact of overweight, governments in the OECD have responded by developing overarching national action plans addressing the determinants of overweight. These include, but are not limited to, policies to guide national dietary and physical activity guidelines, as well as adult and childhood overweight specific strategies. As shown in Figure 2.8, all OECD and EU27 countries have in place multiple national strategies to address high rates of overweight. The data in Figure 2.8 is supported by more recent information collected by WHO which found that, as of 2019, 92% of OECD and 89% of EU27 countries have a national action plan for unhealthy diets and physical inactivity (WHO, 2019[47]; WHO, 2019[48]). A few examples of strategies to tackle the determinants of obesity at the country level are listed below:

  • United States:

    • Active People, Healthy NationSM is led by the Centers for Disease Control and Prevention (CDC) to encourage young people and adults to be more active by 2027

    • Healthy People 2030 sets out data-driven objectives to improve overall health and well-being, including a reduction in the proportion of children, adolescents and adults living with obesity.

  • Australia:

    • The National Preventive Health Strategy 2021-30 (further details are available in Box 1.2).

Plans at the national level align with international policies to tackle overweight. Overweight is global issue affecting both developing and developed countries. In response, the international community has responded by developing overarching goals and strategies to address this growing public health issue. Prominent examples include:

  • The United Nation’s (UN) Sustainable Development Goals, which has a target to reduce premature mortality from NCDs by one-third through prevention and treatment by 2030

  • WHO’s Global Action Plan on Physical Activity, which aims to reduce the global prevalence of physical inactivity by 15%, also by 2030

  • WHO’s Physical Activity Strategy for the WHO European Region 2016-25, which provides a blueprint to incentivise Member States to act (WHO, 2013[53]; Breda et al., 2018[54])

  • Europe’s Beating Cancer Plan recognises that obesity is a key risk factor for cancer and therefore must be addressed (European Commission, 2021[55])

  • The EU’s Farm to Fork Strategy, which among other things, aims to ensure people have access to nutritious foods (European Commission, 2019[56])

  • The two-year campaign, HealthyLifestyle4All (EC, 2021[57]), which is a follow-up of the Tartu Call for a Healthy Lifestyle, was launched in September 2021 to showcase the European Commission’s continuous commitment to promoting a healthy lifestyle across generations and social groups.

Comprehensive policy packages that draw upon international best practice are necessary to tackle the determinants of overweight. Overweight is a complex issue that affects people from all different backgrounds and ages. For this reason, no single policy can tackle this health issue, rather, a suite of complementary policies that create an environment supportive of healthy eating and physical activity is needed. At a high-level, OECD has grouped policies to tackle overweight into four broad domains (Figure 2.9). These domains align with frameworks and policy advice from the WHO, including “Best Buy” interventions for preventing and controlling NCDs, as well as the Global Action Plan on Physical Activity (2018-30) (WHO, 2018[58]).

Subsequent chapters to this report analyse 12 interventions targeting overweight risk factors – i.e. unhealthy diets and/or physical inactivity. Table 2.2 lists each analysed intervention accompanied by a high-level description. The vast majority of interventions analysed in this report reflect policies that aim to influence people’s choices (see Figure 2.9) – for example, by providing education on how to eat more nutritious foods and be more active, as well as labelling foods to highlight those associated with a healthy diet and weight loss.


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← 1. For adults, WHO define overweight and obesity as having a BMI >=25Kg/m2 and 30Kg/m2, respectively. BMI is the most widely used proxy for body adiposity to assess population-level rates of overweight, as it is easily derived from a person’s weight and height (i.e. weight (kg) divided by height in metres squared) (WHO, 2019[59]).

← 2. Metabolic equivalent of task (MET) is a measure to reflect the intensity of physical activities, and allows comparison between them. One MET is the energy equivalent expended per unit of time by an individual while seated at rest. More intense activities, which cost more energy expenditure than being seated at rest, are attributed higher METs.

← 3. Microbiota diversity “a measure of how many different species and, dependent on the diversity indices, how evenly distributed they are in the community. Lower diversity is considered a marker of dysbiosis (microbial imbalance) in the gut and has been found in autoimmune diseases and obesity and cardiometabolic conditions, as well as in elderly people” (Valdes et al., 2018[60]).

← 4. Includes all OECD countries, non-OECD European countries, non-OECD G20 countries as well as OECD accession and partner countries.

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