PROCEEDINGS

The Diabesity Crisis Jim Mann, Rachael Taylor, Wayne Cutfield

wo recent events in March 2017 (‘The a multitude of ways, including limiting Diabesity Crisis’ Symposium and exposure to the temptation of consuming Tthe ‘Cost of ’ Forum) hosted in energy-dense foods (eg, the dessert menu in Auckland by the Edgar Diabetes & Obesity a restaurant). Research Centre (EDOR) and two National The extent to which such support systems Science Challenges: Healthier Lives and can be implemented in primary care or in A Better Start aimed to be more than just other community settings depends upon the another ‘talkfest’ about the related epidem- availability of resources, but surprisingly ics of obesity and (T2DM) in they have rarely been tested. However, we New Zealand. do know that a straightforward nurse-led The organisers asked a group of interna- support programme can be as effective, and tional and national speakers with expertise indeed much less costly, than more intensive in , endocrinology, genetics, weight management programmes involving Māori health, nutrition, physical activity, specialist guidance for maintaining weight public health and clinical medicine to loss.1 Kirsten Coppell discussed the evidence summarise the current state of knowledge base for the provision of dietary advice by and new research in order to identify prior- primary care practitioners. Several models ities for action. have been reported to achieve weight loss, Given the ever-increasing number of obese but there is little information regarding 2 children and adults in New Zealand, many long-term outcomes or cost effectiveness. with T2DM, developing a rational approach Currently, available drug treatments to prevention and management is essential. have little or no place in the management An important fi rst step is the acceptance that of obesity, so unsurprisingly the role of obesity, if untreated, is a chronic progressive bariatric surgery was an important feature disease associated with the early devel- of Rachel Batterham’s contribution to opment of comorbidities and reduction of the Symposium. The most widely under- life expectancy. Rachel Batterham, Tony taken procedure, laparoscopic sleeve Merriman and Dave Grattan all empha- gastrectomy, has a very low rate of compli- sised the role of genes and the powerful cations (similar to that of gall bladder biological mechanisms which can explain surgery) and as is the case with gastric how overweight and obesity develop as a bypass surgery, which is often still under- ‘normal’ response to the current ‘obesogenic’ taken in people with diabetes, is associated environment. Increasing awareness that with substantial weight loss as well as an obesity, like other major chronic diseases, appreciable improvement in comorbidities, results from an interaction between biology notably T2DM. Typically there is an imme- and environment helps to shift the dialogue diate post-surgical improvement in blood from a position of blame to one of solution levels. Dosage of hypoglycaemic and the development of a more rational agents (oral hypoglycaemics and insulin) is approach to management. invariably reduced and often may no longer What then should we offer to the obese be necessary. patient? An important message to be taken Current criteria for surgery in New Zealand from Rachel Batterham’s presentation is are more rigid than in most Western coun- that powerful biological mechanisms also tries, and while surgery is not appropriate hamper maintenance of initial weight for all obese patients, the criteria certainly loss achieved by energy restriction. So, warrant an urgent review, especially as they approaches which provide long-term apply to obese patients with T2DM. In the support and encouragement are essential. UK it is recommended that all patients with These include targeting physical activity, recent onset T2DM and a body mass index sedentary behaviour, sleep and diet in (BMI) greater than 35kg/m2 be assessed for

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the possibility of bariatric surgery after availability, relatively low cost and largely non-surgical measures have been tried unrestricted advertising all contribute without sustained weight loss. This might to overconsumption of sugar-sweetened be a useful starting point for the discussion beverages (SSBs) and energy dense foods, about extending the criteria for surgery in which are considered to be major contrib- New Zealand. utors to excessive energy intakes. Callie Corrigan discussed issues relating Louise Baur provided strong evidence that to bariatric surgery, which are particu- intensive early childhood interventions can larly relevant to Māori. Individuals will reduce the risk of excessive weight gain, have a much more successful experience of especially in socio-economically disadvan- bariatric surgery if they are supported by taged groups who have high rates of obesity their whānau, especially the key decision and little access to such programmes. makers around kai. The challenge for However, the benefi ts are not sustained if health professionals is to provide infor- the intervention is not maintained in the mation and support, not only to individuals longer term. These fi ndings are hardly but also to their whānau. Information surprising given the pervasive nature of the needs to be provided in accessible formats, obesogenic environment, clearly illustrated taking account of Māori whakapapa and by Louise Signal using the photographic utilising oral and visual forms of commu- records of a group of New Zealand children nication as well as written ones. And wearing cameras, which continuously to enable patients to move in a positive recorded the environment to which they direction, support needs to be provided were exposed during their waking hours. from a safe, comfortable and neutral place While diet is often considered the corner- (without negative labels) that respects and stone of obesity management, behaviours values people. This can sometimes be as on the other side of the energy balance simple as having seats that are the right equation are just as important. Dave Lubans size. The capacity of the Māori health sector summarised the effectiveness of different must be increased in order to develop more approaches to increasing physical activity equal partnerships. and reducing sedentary behavior, particu- While bariatric surgery offers hope for larly in adolescents. The potential benefi ts people who have been unable to lose weight of resistance training for reducing adiposity by other means, a greater long-term hope and enhancing insulin sensitivity and the lies in developing medical therapies which appeal of high-intensity interval training mimic the mechanisms by which bariatric for overweight, but often very strong surgery achieves weight loss, reversal or adolescents should not be underestimated. improvement of comorbidities, and facil- Reducing the decline in physical activity itates the maintenance of weight loss. which typically occurs in adolescence and Professor Batterham especially emphasised developing more innovative approaches the central role of gut hormones as medi- to delivering physical activity sessions are ators of the benefi t of bariatric surgery and major challenges with this age-group. as novel targets for the development of Unlike other types of sedentary behaviour obesity therapies. such as screen time, sleep is a sedentary Measures aimed at stemming the tide activity that is clearly good for health. of the ‘diabesity’ epidemic are of equal Rachael Taylor highlighted the consis- importance to therapeutic approaches. tency of the evidence investigating the Given the dramatic increases in obesity relationship between sleep and obesity and T2DM over a remarkably short period in children, indicating that short sleepers of time, there can be little doubt that while have a two-fold greater risk of obesity than biological mechanisms explain predis- long sleepers.3 Moreover, the effect seems position, environmental factors must to persist into adulthood, indicating the account for the current alarming statistics. potential for long-term benefi ts. Confi r- Furthermore, successful maintenance of mation of sleep intervention as an effective weight loss also requires an environment obesity prevention tool is now urgently which is conducive to healthy food choices required. Given the observation that many and regular physical activity. Widespread of the adverse health outcomes associated

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with poor sleep are also more common in school communities to be more proactive Māori and Pacifi c children, it is also feasible about their health and wellbeing but does that sleep interventions hold promise for not include an enforceable healthy school reducing inequities in health. Regardless food policy. The current Code for adver- of their impact on weight, the physical tising food and beverages to New Zealand and mental health benefi ts arising from children and young people is voluntary, a good night’s sleep are numerous. Other and such industry-operated self-regulation novel approaches to obesity prevention rarely delivers benefi t to public health.11 A and management may lie within our gut. tax on SSBs has been one of the most widely Rinki Murphy and Wayne Cutfi eld reviewed discussed obesity prevention measures current evidence, largely from animal internationally, and evidence is emerging studies, suggesting that the gut micro- from countries that have implemented such biome may contribute to a wide range of taxes that they are effective.12 Furthermore, disorders, including obesity and type 2 revenue from a SSB tax could be used to diabetes mellitus. Intervention from healthy support other health programmes.13 donors increases diversity of the gut micro- The issues relating to sugar were discussed biome and has been shown to markedly in some detail at the ‘Cost of Sugar’ Forum improve insulin sensitivity in a pilot study chaired by Kim Hill. Jim Mann summarised of adults with type 2 diabetes mellitus. the science relating to the adverse health Professor Cutfi eld is currently undertaking consequences of free (or added) : a gut microbiome transfer study to treat unequivocal evidence for the role of sugars severe adolescent obesity using a novel as a cause of dental caries; convincing encapsulation method for gut microbiome evidence that high intakes (especially of transfer. Similarly, obesity and diabetes SSBs) contribute to excess weight gain in research is embracing the digital world; Lisa children and to overweight and obesity in Te Morenga highlighted the opportunities adults and that restriction can reverse this; offered by mHealth (mobile health) initia- and accumulating evidence that fructose tives and emphasised the need to establish and fructose-containing sugars (sucrose close relationships with those communities, and high fructose corn syrup) have particu- which are the intended end-users of such larly adverse effects in terms of increasing programmes. Co-design of research projects insulin resistance, T2DM, gout and fatty and programmes by researchers and liver disease. The evidence relating to dental communities (or end-users) is essential. caries and body fatness was the major In 2015, the New Zealand Government determinant of the World Health Organiza- released a childhood obesity plan involving tion’s (WHO) Recommendation that “free 22 initiatives aimed at risk reduction as well sugars should contribute no more than 10% as managing childhood obesity. Speakers total calories and ideally less than 5%”. acknowledged these positive steps but Tony Blakely argued strongly that there Cliona Ni Mhurchu drew attention to several was now suffi cient evidence to implement recommendations4–8 which are considered a tax on SSBs in New Zealand despite the to be important components of public health reservations expressed by Jacqueline approaches to reducing the risk of obesity Rowarth relating to the consequences of a internationally, are consistent features of global reduction of sugar intake for sugar comparable plans in other countries9–10 and producing countries, especially developing are conspicuous by their absence in the New countries with marginal economies. Zealand plan: Callie Corrigan, Alex Brown and others • An enforceable healthy school food present in the audience reminded us all policy of the critical importance of involving the • A government-led code for advertising community, especially the Tangata Whenua food to children and those in high-risk groups when devel- oping approaches aimed at tackling the • A tax on sugar-sweetened beverages. ‘diabesity’ epidemic. Not only is there The New Zealand Health Promoting an obligation to do so, but without such Schools (HPS) Initiative and the Heart Foun- involvement any overall initiative is likely to dation’s Fuelled4Life programme supports be unsuccessful.

NZMJ 21 July 2017, Vol 130 No 1459 ISSN 1175-8716 © NZMA 84 www.nzma.org.nz/journal The New Zealand Childhood Obesity 1. A tax on sugar-sweetened beverages Plan (2015) and the updated guidelines (SSBs) for Management of Obesity in Childhood 2. A government-led code for food (2016) list a number of important initiatives. advertising However, the ‘Diabesity Crisis’ Symposium 3. An enforceable healthy school food and ‘Cost of Sugar’ Forum suggested a policy number of further recommendations for immediate action to help stem the tide of the 4. Review of eligibility criteria for obesity and diabetes epidemic: bariatric surgery 5. Clear recommendations regarding the role of sleep in obesity prevention.

Competing interests: Nil. Author information: Jim Mann, Director, Healthier Lives National Science Challenge; Rachael Taylor, Director, Edgar Diabetes and Obesity Research Centre, University of Otago; Wayne Cutfi eld, Director, A Better Start National Science Challenge. Presenters: Rachel Batterham, Louise Baur, Tony Blakely, Alex Brown, Kirsten Coppell, Callie Corrigan, Wayne Cutfi eld, Dave Grattan, Kim Hill, David Lubans, Jim Mann, Tony Merriman, Rinki Murphy, Cliona Ni Mhurchu, Jacqueline Rowarth, Louise Signal, Rachael Taylor, Lisa Te Morenga. Corresponding author: Professor Jim Mann, Department of Medicine, University of Otago, PO Box 56, Dunedin. [email protected] URL: http://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2017/vol-130-no-1459- 21-july-2017/7324

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