Solving obesity without addressing poverty: Fat chance

Fig. 1. Obesity rates in the US and worldwide. (A) Indicates the quartiles for obesity rates ranked by median household income for 3140 United States counties. (B) Indicates the quartiles for obesity rates ranked by per capita gross Domestic Product for 105 Countries. Data from [26], GDP per capita (current US$). World Development Indicators. World Bank. http://data.worldbank.org/indicator/ NY.GDP.PCAP.CD/countries?display=default. Last updated July 1, 2015. Accessed July 9, 2015 and Global Overweight & Obesity: Prevalence of overweight and obesity in adults around the globe. Obesity data portal. World Obesity Federation. http://www.worldobesity.org/aboutobesity/resources/obesity-data-portal/resources/ tables/10/ Last updated June 17, 2015. Accessed July 9, 2015. Obesity and being overweight kill more people in most countries than being underweight [1]. Worldwide, in 2014, about two billion adults were overweight and 600 million people had obesity. The disease burden of obesity/overweight will get worse for several reasons. First, the present generation of obese children will mature; currently >40 million children under 5 years old are overweight or obese [1]. Second, more countries are identifying obesity as a key driver of healthcare costs. Third, additional obesity comorbidities are being recognized, diagnosed and treated; one example is obesity-associated non-alcoholic steatohepatitis. About two thirds of people older than 50 with diabetes or obesity, which represents 75–100 million North Americans, have non-alcoholic steatohepatitis and are at risk of developing advanced fibrosis [2–4]. Considering that most people who have steatohepatitis do not know it [4] and that in some countries type II diabetes affects 1 in 3 adults [5,6], obesityassociated liver disease is a catastrophe in the making. Moreover, obesity is also associated with an increased risk of hepatic decompensation irrespective of the etiology of cirrhosis. Internationally, wealthier countries have more obesity than poorer ones [1]; moreover, as countries become wealthier and urbanize, obesity rates increase [7]. Obesity is a yardstick of national economic vitality [8–11]; in contrast, low income countries in Asia, the Pacific or Africa [12,13] house 842 million malnourished people [14,15]. The Organization for Economic Cooperation and Development (OECD), focusing on the world’s wealthiest nations, reports that more than half of people in OECD countries are overweight or have obesity. Of the OECD countries, the United States has among the greatest rates of obesity (35% of women and 34% of men) [16]. Projections suggest that by 2020, three-quarters of North Americans may be overweight or obese. The paradox (Fig. 1) is that although the wealthiest countries may have the highest rates of obesity, it is not the wealthiest Americans who are obese but the poorest. North Americans living in the 100 poorest counties are 34% more likely to have obesity and 60% more likely to have diabetes compared to people living in the wealthiest 100 counties, who have 6-fold higher incomes. For example in Ziebach County, South Dakota, 37% of the population suffer from obesity, 54% live in poverty and the median household income is $25,592/year. By contrast in Douglas County, Colorado the obesity rate is 16%, the poverty rate 3% and median household income is >$100,000/year.