WHO recognition of the global obesity epidemic

Abstract

The recognition of obesity as a disease was in theory established in 1948 by WHO's (World Health Organization) taking on the International Classification of Diseases but the early highlighting of the potential public health problem in the United States and the United Kingdom 35 years ago was considered irrelevant elsewhere. The medical profession disregarded obesity as important despite the new evidence and WHO data set out in the 1980s. Only in 1995 did WHO find greater problems of overweight than underweight in many developing countries but it required the first special obesity consultation in 1997 and particularly the Millennium burden of disease analyses to suddenly highlight its crucial role in the current unmanageable and escalating medical costs globally. Governments now recognize the overwhelming industrial developments that guarantee an escalating epidemic but neither they nor WHO know how to engage in changing the societal framework to promote routine spontaneous physical activity and a transformation of the food system so that low energy-density food of high nutrient quality becomes the norm.

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REVIEW
WHO recognition of the global obesity epidemic
WPT James
London School of Hygiene and Tropical Medicine, International Obesity TaskForce, London, UK
The recognition of obesity as a disease was in theory established in 1948 by WHO’s (World Health Organization) taking on the
International Classification of Diseases but the early highlighting of the potential public health problem in the United States and
the United Kingdom 35 years ago was considered irrelevant elsewhere. The medical profession disregarded obesity as important
despite the new evidence and WHO data set out in the 1980s. Only in 1995 did WHO find greater problems of overweight than
underweight in many developing countries but it required the first special obesity consultation in 1997 and particularly the
Millennium burden of disease analyses to suddenly highlight its crucial role in the current unmanageable and escalating medical
costs globally. Governments now recognize the overwhelming industrial developments that guarantee an escalating epidemic
but neither they nor WHO know how to engage in changing the societal framework to promote routine spontaneous physical
activity and a transformation of the food system so that low energy-density food of high nutrient quality becomes the norm.
International Journal of Obesity (2008) 32, S120–S126; doi:10.1038/ijo.2008.247
Keywords: obesity; anthropometry; disease burden
Introduction
Formation of WHO with obesity already classified as a disease
WHO (World Health Organization), when it was established
in 1948, had not only to consider for the first time the global
pattern of diseases and their prevention, but also incorporate
pre-existing international work on any major health issue.
The International Classification of Diseases (ICD) had
already been formally adopted for international use by
1900 because pathologists were anxious to have an agreed
set of criteria for comparing disease rates. So, in 1948, the 6th
ICD version was set out by WHO and covered a huge range of
problems from infections and parasitic disease, congenital
abnormalities, cancers, cardiovascular diseases and neurolo-
gical disorders to such issues as accidents and violent deaths.
It is interesting, therefore, to note that obesity was then
specified as a disease and this has been retained throughout
the updating process. Thus, in 1975, the ICD 9 version had
‘obesity and other hyperalimentation’ registered in cate-
gories E65–67. Then a clinical modification was introduced
in the United States in 1979, with morbid obesity added in
1995 before ICD 10 was phased in during the mid 1990s. So
throughout more than the last half century, pathologists and
WHO have recognized obesity as a disease.
Obesity ignored: of little clinical significance
The ICD depended upon a pathologist’s view of the post-
mortem experience. The rest of the medical world, however,
was concerned with clinical issues and their management. To
them, any clinical difficulties induced by obesity were
readily curable by simply reducing food intake. This required
discipline by the patient as advised by their doctor. They
considered any major nutritional problems to relate to the
‘developing world’. The only exceptions seemed to be the
nutritional complications of gastrointestinal disease or
unusual genetic abnormalities and children’s needs for
growing well.
Keys: obesity is not a risk factor for cardiovascular diseases
The neglect of obesity by medical authorities can probably be
traced to the remarkable Seven Country Studies
1
on
cardiovascular disease (CVD), initiated by Ancel Keys who
was already famous for his classic experiments on the effects
of semi-starvation in conscientious objectors. Keys, with a
combination of meticulous metabolic feeding studies on the
determinants of blood cholesterol levels, together with
metabolic epidemiological assessments of middle-aged men
in Japan, Mediterranean countries, Northern Europe and the
United States, had shown that there was no relationship
between obesity and the prevalence or death rates from
stroke or coronary heart disease. Keys insisted on excluding
obesity as a problem because Greek men had the highest
body mass indices (BMIs) but very low rates of cardiovascular
disease. Other epidemiologists such as Shaper,
2
in his studies
Correspondence: Professor WPT James, IASO offices, Lower Ground Floor 28,
Portland Place, London W1B 1DE, UK.
E-mail: JeanHJames@AOL.com
International Journal of Obesity (2008) 32, S120–S126
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of rural recruits to the Kenyan army, did note that on transfer
into the army and an urban environment, body weights,
blood pressure and serum cholesterol all rose, and much of
their discussion involved the role of increased body weight
and body fat. There were also, however, marked increases in
salt and dietary fat intakes.
WHO began to become concerned about CVDs in the
1970s. Keys had already persuaded the American Heart
Association to launch campaigns to reduce saturated fat
intake and, in 1962, the Norwegian Government had
established the first coordinated strategy to limit the
accelerating epidemic of heart disease.
3
Given these devel-
opments, WHO established the MONICA Surveys as sentinel
surveys for monitoring differences and changes in CVDs in
middle-aged men and women in many countries globally.
4
Heights and weights were included in the measurements but
these were routine additions rather than important criteria.
Early national initiatives on obesity
Obesity only became an issue of potential government
concern in the mid-1970s when Bray produced the Fogarty
reports in the United States
5
and we, in the United Kingdom,
reported on research needs in obesity for the government
and the Medical Research Council.
6
These reports stimulated
the establishment of research centres, but little further
government action, and WHO considered this was not their
concern because their priority lay with the problems of the
so-called Third World. By the early 1980s, a further major
report for the London Royal College of Physicians high-
lighted the public health implications of obesity,
7
this being
hailed by their Council as their most important report since
Doll’s analysis of the hazards of smoking. Again, however,
the UK government and WHO ignored the issue.
WHO/FAO/UNU report on protein and energy requirements
In 1981, a conjoint UN panel was organized to reassess
protein and energy requirements and obesity again impacted
on these analyses. Our research at the MRC Clinical
Nutrition Centre in Cambridge, UK with whole body
calorimeters, built to study the energy needs of volunteers
and obese patients, proved particularly valuable. The energy
metabolism of adults was found to be remarkably well-
controlled: if fed the same intake and exercised under
controlled conditions, the 24 h energy expenditure varied
by less than 2%. Furthermore, the huge range in the energy
requirements of the population, when expressed as the total
energy output on a 24 h basis, could be standardized by
expressing each individual’s value as a ratio of their BMR
(basal metabolic rate); this ratio was designated as the
physical activity level. The analysis on the basis of the
physical activity level immediately rationalized the differ-
ences between individuals. As the variation in daily energy
expenditure was much less than daily intake changes, a
simple evaluation of energy output then allowed a specification
of food needs provided body weight was stable. The focus on
energy output was reinforced when it was shown that obese
individuals usually underestimated their intake as they
constantly tried to limit their food intake. Furthermore, a
reanalysis of the supposed energy efficiency of people in the
developing world revealed spurious data based on reported
low intakes when their higher corresponding energy ex-
penditure values were remarkably similar to those predicted
from the Cambridge calorimetric work.
8
At the UN meeting in Rome, the preliminary BMR data
seemed flawed by including adolescent data in the adult
analyses, so fundamental recalculations of energy needs were
required. This led to the current predictions of BMR for
children and adults throughout the world
9
and a calculation
of all the physical costs of exercise provided by different
reports, which could again be standardized by expressing
them as a ratio to the predicted BMR.
10
This report, now
considered a classic, was used to consider world food needs
and the prevention of malnutrition.
11
The analyses of energy
requirements, however, did lead to a more rational analysis
of different people’s food needs based on their physical size
and occupational profiles.
10
Again obesity was not a priority.
WHO strategies for the prevention of cardiovascular disease
In 1984, Geoffrey Rose from London and Henry Blackburn
(Keys’ successor) from Minnesota produced their first classic
report on the prevention of CVDs.
12
They argued for a
population-wide strategy by highlighting the importance of
reducing the average cholesterol level of the population as
well as treating those with severe hypercholesterolaemia.
They set a 15–30% range for fat intakes with the upper figure
chosen because US and Northern European fat intakes were
42–43%, and the 15% value came from WHO’s international
perspective and the recognition that most Asian countries
were eating o15% fat. Reducing total fat intake to 30% was
primarily a pragmatic decision to reduce saturated fat
intakes, and obesity was not an issue, given the epidemio-
logical view that simply considered weight gain as a risk
factor for high blood pressure and increased blood choles-
terol levels.
The WHO European 1988 and WHO 797 report in 1990
The first Nutrition and Chronic Disease Report for the
European Region of WHO
13
had a separate chapter on
obesity highlighting its importance in 1988 and these
analyses led to the WHO Geneva having the first global
Expert Technical Consultation on Diet, Nutrition and the
Prevention of Chronic Diseases. The resulting 797 report
produced an integrated analysis of the global problems, and
again obesity had its own section, with the link to dietary fat
being highlighted by showing the progressive increase in
BMI in Brazilian men with increasing dietary fat whatever
the sources of fat in their diets.
14
However, the 797 report
immediately became highly controversial because sugar
WHO and the obesity epidemic
WPT James
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International Journal of Obesity

intake goals were set within the 0–10% energy range based
on the non-essentiality of sucrose and its role in promoting
dental caries. Observers from the food industry immediately
warned the global network of sugar interests of the perceived
threat to their business expansion. It was therefore not
surprising to find two powerful national representatives
at the WHO Executive Board questioning the validity
of the report without being able to present any scientific
arguments.
WHO anthropometric criteria for health
By the early 1990s, the prevalence of childhood malnutrition
had become a major political issue so there was a need to
ensure appropriate methods for its assessment. WHO
convened four teams in 1993 to consider how to assess a
nation’s problem of either malnutrition or obesity in both
children and adults. The childhood obesity criteria were
simply set on the usual WHO statistical basis as that
equivalent to weight-for-heights in excess of þ 2 s.d. limit.
WHO also accepted our earlier specification of the three
grades of adult chronic energy deficiency
15
as ‘underweight’
with BMI cut-points of 16.0, 17.0 and 18.5 kg/m
2
. The
overweight and obesity group defined overweight as obesity
related to a BMI of 25–29.9 kg/m
2
(grade 1), with grade 2
overweight commonly termed as obesity specified for a BMI
of 30–39.9 kg/m
2
, and grade 3 or morbid obesity as applying
to those with BMI X40 kg/m
2
. This technical report was seen
as a background document with no particular policy
implications.
WHO reluctance to recognize obesity as a global problem
By 1995, obesity in the Western World had become a major
issue for obesity specialists but still many national govern-
ments refused to take it seriously. The United Kingdom,
however, in that year had produced a report on the
prevention of obesity
16
and at the same time the Scottish
Royal College of Physicians were attempting to cope with the
challenge of managing so many obese patients by drawing
up new management guidelines.
17
Nevertheless a small
group of frustrated physicians was considering how to
galvanize a new approach by the medical establishment
and Ministers of Health. The International Obesity TaskForce
(IOTF) was therefore established with the express purpose of
having a special consultation in WHO Geneva, which would
be solely devoted to obesity. The difficulty with this
proposition, however, was that WHO officials considered
that obesity was a problem for the affluent Western world
and irrelevant to Third World concerns; it could therefore
not legitimately be handled by WHO Headquarters. This
view was maintained despite earlier analyses included in the
WHO anthropometry report showing that overweight and
obesity were far more prevalent than underweight in
adults living in Latin America and North Africa, and only
South-East Asia and those countries exposed to famine and
war had high levels of chronic energy deficiency.
Despite this WHO resistance, the IOTF established
11 subcommittees and a Council of global leaders to collate
the evidence on obesity with a special effort to include
developing country issues although at that stage not much
relevant work was available. However, having proven with
additional data that obesity was becoming a problem in the
developing world, WHO agreed to hold a meeting but only if
it was delayed for 6 months so that both FAO (Food and
Agriculture Organization) and WHO could hold a special
technical consultation on carbohydrates. FAO and WHO
were separately supported in this endeavour by the Interna-
tional Life Sciences Institute (ILSI), the organization estab-
lished by the food industry to interact with academics,
governments and the public. As expected, the original FAO
report exonerated sugar from any blame for dental caries and
the issue of obesity was not included as a major issue relating
to sugar. An attempt was also made to finalize the measure-
ment of fibre so that many routine products, for example,
cornflakes, could be labelled as high in fibre when in practice
they had little or no non-starch polysaccharides, but con-
tained many products of the Maillard reaction between the
sugar and amino acid components of the food. This report
was subsequently set aside as having been conducted in an
improper manner and a new report has now been issued.
18
When the WHO Obesity meeting was finally convened,
the IOTF draft became the working basis for the meeting and
in practice, only minor modifications to the report were
made. The nomenclature of overweight was retained but an
additional cut-point of BMI 35 kg/m
2
was included in the
obesity range. Despite some suggestions from WHO officials
that sugar needed to be included in the range of factors
contributing to obesity, at that stage the IOTF drafting group
had not collated strong enough evidence to warrant a
specified limit on sugar intake. The report did not highlight
sugar as a problem but did conclude that, from an obesity
point of view, the fat intake of a population should probably
not exceed 20–25% rather than the earlier designated 30%
value set for CVD.
The meeting was conducted as a full Expert Technical
Consultation, but in practice this proposal had not been
agreed by the WHO Executive Board as part of its Biennial
Plan. Nevertheless discussions with the then Director
General, Dr Nakajima, led to WHO’s acceptance that they
would need to take it through a process that allowed the
report’s inclusion in the official Technical Report Series.
These are formally accepted by the WHO Executive Board
and have an almost legal basis as far as most national
governments in the developing world are concerned, despite
the routine statement by WHO that the views of the expert
groups do not necessarily reflect that of WHO.
As usual, the whole document had to be re-edited by WHO
so that the language was sufficiently explicit to allow its
translation into the other official languages. However, there
was a huge backlog of reports being processed, so WHO
WHO and the obesity epidemic
WPT James
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International Journal of Obesity

agreed to issue an interim document in English in 1998,
which IOTF then distributed directly to every Minister of
Health in the 192 member countries. It was subsequently
produced in the standard format of WHO Expert Reports.
19
WHO global burden of disease analyses
The importance of the WHO obesity report was enormously
enhanced when WHO decided to undertake an exceptionally
ambitious task of assessing what the principal risk factors are
for the total burden of premature death and disability on a
global basis. The IOTF was asked to asses global weights and
heights and where possible produce regression equations for
the development of as many of the WHO defined diseases as
could be shown to be induced or amplified by weight gain.
The counterfactual process required a specification of the
ideal values for average body weights for the whole
population in each designated age group rather than
pragmatic targets for body weight changes. This, together
with the ideal standard deviation of the mean weight range
and the WHO estimated disease and death rates, allowed the
attributable effect of excess weight, that is, from any increase
above the ideal, to be assessed quantitatively for all the major
diseases in the designated 14 subregions of the world. These
analyses have been presented extensively
20,21
and revealed
that excess adult BMIs were in the top 10 risk factors for the
burden of disease whether one was considering the high-
income countries of Japan and the West or the low and
middle income countries of what used to be termed the
developing world. Since then the analyses have been
updated by WHO in conjunction with the World Bank
and, in their 2006 assessment, excess weight gain had moved
up to the third rank as the most important risk in high-
income countries.
22
The data incorporated estimates of the
impact of excess weight gain on several cancers, which were
also being considered by a special group working for the
International Agency for Research on Cancer which is part of
WHO.
23
Regional WHO initiatives: Western PacificFOceania
The early recognition that Asians usually had appreciably
lower BMIs and that the comorbidities seemed to become
evident with very modest increases in weight, led to a
meeting of the Western Pacific Regional Office of WHO,
together with the International Association for the Study of
Obesity and IOTF representatives in Hong Kong in 2000. On
the basis of preliminary receiver operating characteristic
analyses of the likelihood of co-morbidities being present at
different levels of BMI it was decided to take the cutoff point
for overweight as a BMI of 23 kg/m
2
. By then the Japanese
government was already considering that obesity was to be
specified when BMIs exceeded 25 kg/m
2
. This meeting was
not, however, a wide ranging consultation on the appro-
priateness of Asian criteria; this had to wait until a larger
meeting could be convened in Singapore in 2002.
24
Pre-
liminary data according to a predetermined IOTF plan was
assembled
25
but further analyses available at the Singapore
meeting allowed a careful scrutiny of many national and
regional datasets. At that stage it seemed that perhaps
relating comorbidities to body fat levels of the different
ethnic groups might be more appropriate than simply
considering BMI as the first reference point. However, it
was recognized that Indians had the highest proportion of
body weight as fat, this being evident from birth. The
Chinese and Malays had less body fat but still more than that
observed in Caucasians. However, in Thailand, the rural
Thais were more like Caucasians, whereas urban dwellers,
already showing marked increases in BMI and comorbidities,
had intermediate proportions of body fat similar to those of
the Chinese. This implied that there was some environ-
mental factor that determined the proportion of lean and fat
tissues. The Singapore meeting finally concluded that in Asia
the optimum values for overweight and obesity using similar
criteria varied. Most governments would need to think about
both therapeutic and preventive initiatives for those with
BMIs above 23 kg/m
2
; an intermediate level of BMI 27.5 kg/
m
2
was suggested as another potential cutoff point in Asia
for those with a substantially increased risk of comorbidities.
By then the Chinese academic community had combined
their data and suggested that the overweight cutoff point
should start at a BMI of 24 kg/m
2
, with a pragmatic choice of
BMI 28 kg/m
2
for specifying obesity and the need for detailed
management.
Pan American Health Organization
The Pan American Health Organization (PAHO) did not
initially consider obesity as a problem until Pen
˜
a and
Bacallao assembled data from a number of countries in
Central and South America; they showed that obesity was
now a feature linked to poverty and often associated with
coexisting malnutrition in families as well as in the general
community.
26
IOTF had already helped to stimulate devel-
opments in the Caribbean, linked to PAHO initiatives, with
Barbados taking the lead at a Commonwealth Health
Ministers Conference in 1998. An evaluation of progress in
2002 showed that PAHO, in association with the Chief
Medical Officers of Health of each of the Caribbean
countries, had agreed on a prevention strategy but the
academic community and civil society seemed unaware of
these initiatives. So it looked as though at that time too
much reliance had been placed on governmental action.
WHO 916 report on diet, physical activity and chronic disease
This consultation in effect revisited the issues dealt with
11 years previously in the 1990 797 report.
27,28
However,
on this occasion it was decided not to include the problems
of childhood malnutrition and because WHO had already
enacted its first international law relating to tobacco
restrictions, this initiative became immediately a high-profile
WHO and the obesity epidemic
WPT James
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International Journal of Obesity

event. Derek Yach, the WHO Assistant Director General of
Chronic Disease, developed an open consultative process so
that proposals and assessments of the draft report could be
taken on board. On this occasion obesity became a
prominent if not dominant feature and it was concluded
that obesity prevention needed restricted sugar intakes and
markedly reduced food energy densities. Otherwise the
population goals were very similar to the original 797 criteria
and, interestingly, the upper fat goal was not reduced below
30 kg/m
2
, this value again being set by the cardiological
group.
The 916 report became highly contentious after its launch
by the Director Generals of both WHO and FAO in Rome in
2003, when over 100 Ministers of Agriculture rejected its
analysis and conclusions at their next annual FAO meeting.
The Ministries of Agriculture were again of the opinion that
the sugar goals were unscientifically derived and would have
a damaging effect on the economies of the developing world.
The Ministers rejected the validity of the 916 report despite
FAO setting out the agricultural opportunities. Additional
World Bank analyses confirmed that the overall implications
of the 916 report were of substantial benefit to farmers in the
Third World. They would benefit even further if Europe and
the United States abolished their selective import tariffs and
export subsidies, which currently distort world food prices,
particularly of fats, oils and sugars.
WHO global strategy on diet and nutrition
After the 916 report, WHO attempted to start a practical
scheme to combat obesity and chronic diseases by having
the World Health Assembly in 2002 agree on a preventive
strategy. This strategy was only agreed upon after member
states agreed to remove any reference to the WHO 916
report. Delegations from several low and middle income
countries opposed reference to the supposedly flawed sugar
section and concerns for coconut oil interests. Despite these
objections, WHO, with the help of the South African
Minister of Health, finally obtained agreement for the global
strategy.
WHO Kobe meeting on childhood obesity
A major effort by many obesity experts went into preparing a
WHO meeting in Kobe, Japan in 2005 dealing specifically
with childhood obesity. A new IOTF report on childhood
obesity was initially produced
29
followed by further exten-
sive drafts. The Kobe report has been finalized but has still
not been published by WHO 3 years after the meeting.
WHO European initiatives
European action plan. WHO Euro had a long tradition of
innovative work in dealing with the problems of CVDs and
in 2004 finalized a comprehensive report,
30
which drew
heavily on some of the new approaches to environmental
change for obesity set out by the IOTF’s prevention group.
WHO also extended Swinburn’s analyses of micro and macro
environmental changes in the physical, economic, policy
and cultural domains and extended the medical concept of
prevention by including aspects of food safety and agricul-
tural sustainability. This reflects the need in government for
an integrated approach to policy making. The WHO EURO
office also stimulated a large number of countries, beginning
in Scandinavia, to evolve new action plans to combat
obesity.
Istanbul consensus on obesity. Following the 916 report, the
WHO EURO office decided that obesity was becoming
such a problem in Europe that a major meeting was
needed for all the Ministers of Health and a substantial
background document was produced for governmental
use.
31
A draft of a Charter to drive home the need for action
rather than just grand pronouncements was also produced.
The Charter was agreed after intense negotiations of every
phrase. Nevertheless, the 48 Ministers signed the Charter
that emphasized the importance of regulatory and other
government led initiatives and sought radical preventive
measures.
32
PAHO Caribbean prime ministerial meeting
More recently, after extensive work as personal advisor to the
Prime Ministers of the Caribbean by Sir George Alleyne,
ex-Regional Director of PAHO, a one-day meeting of 16
Prime Ministers was convened in Trinidad in September
2007 with WHO Geneva and PAHO support. This meeting
focused on adult chronic diseases but with an emphasis
on the problems of tobacco use and obesity. An agreed plan
was announced to implement ever more stringently the
Tobacco Framework and all Ministers of Health now have to
devise an intersectoral plan by the summer of 2008 to
counteract obesity, which the Prime Ministers recognize is
leading to unsustainable medical costs for diabetes, hyper-
tension, stroke and coronary heart disease throughout the
Caribbean.
Following this meeting PAHO is supporting multiple
initiatives in different parts of Latin America and special
meetings are due in Chile with other regional meetings
planned for late 2008. It is also planned that the (British)
Commonwealth Heads of Government meeting in 2009 in
Trinidad will feature a special session on obesity and the
prevention of chronic diseases.
Conclusions
Although governments and academics in North America and
Northern Europe see WHO as a valuable resource to help
other countries combat their medical problems, WHO is in
fact enormously influential in steering the thinking of most
governments. It has relatively modest means for the
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WPT James
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International Journal of Obesity

enormous demands made on it but it can draw on global
expertise to produce very authoritative reports and advisory
documents. Nevertheless, it is not often realized that the
World Assembly delegations agreeing new policies are
essentially controlled by the foreign services of the member
states and they often overturn the views of their own
Ministries of Health if there are strong economic arguments
from the Trade or Agriculture departments.
Some countries, particularly the United States under the
Bush administration, have also led a movement to persuade
other member states that WHO should merely be the servant
of its membership and not take the lead that was the
strength of WHO, for example, during the years when Drs
Mahler and Harlem Brundland were Director Generals.
Obesity has become a highly contentious issue in part
because the United States not only has one of the highest
obesity rates in the world but has also led the industrial
transformation of society to produce the ‘toxic environment’
now accepted by most governments as the problem. The UK
Chief Scientist, who produced the recent UK Foresight report
on Obesity considered that obesity is another outcome of a
failure in the reliance of governments on the free market to
solve medical and social problems. The food chain and the
oil, car, road-building, TV, entertainment and advertising
industries themselves often specify that some of their
members may have contributed to the obesity epidemic and
are understandably concerned with ensuring that their
financial interests are not compromised by government
intervention. The work of academics and others in the public
sector is therefore vital and needs to continue to support a
beleaguered WHO. The highlighting of obesity as a major
public health issue is now uncontroversial (except perhaps in
the United States) but the principal and radical practical
steps needed to reverse this epidemic is the next challenge.
Conflict of interest
The author has declared no conflict of interest.
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