greek nat report eng

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Pr ev en t iv e Med ic in e

& Nut r i t ion Cl in ic

Facu l ty o f Med ic in e

Un ivers i ty o f Cre te

Greece

PORGROWNEST INSI GHT


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.. .... ..

Caroline CODRINGTON

Katerina SARRI

Anthony KAFATOS


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Acknowledgements

The Greek research team of the PorGrow project would like to thank all the

participants who were interviewed and generously gave their time to the project. We

are equally grateful to the team of SPRU, University of Sussex, UK and especially

Professor Erik Millstone and Professor Andy Stirling for their support and guidance

throughout the project.

Disclaimer

The results discussed in this report represent the individual points of view of those

interviewed. They are presented in a format that is true to the Multi Criteria Mapping

methodology, and are therefore a consequence of this method, including its

constraints. These results cannot therefore be taken as representing the official

positions of the institutions, organisations or associations in which the individuals

interviewed work.


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Executive Summary

Section 1 Epidemic of obesity 11.1 Overweight and Obesity in Adults

1.1.1 Criteria

1.1.2 Prevalence

1.1.3 Age-related prevalence

1.1.4 Severity

1.1.5 Sociodemographic characteristics

1.1.6 Secular trends

1.1.7 Interpretation

1.2 Overweight and Obesity in Children1.2.1 Prevalence

1.3 Conclusion

Section 2 Estimated Costs of Obesity......122.1 Human Costs: Health Risks and the Burden of Disease2.2 Morbidity and Mortality in Greece2.3 Health Care Costs2.4 Other Economic Costs2.5 Conclusion

Section 3 Trends in food consumption and physical activity....233.1 Causal Influences3.2 Trends in food consumption

3.2.1 Changing food patterns

3.2.2 Shifting dietary habits

3.2.3 Past and Present3.3 Physical Activity

3.3.1 Patterns of Activity : Adults

3.3.2 Patterns of Activity : Children and Adolescents

3.4 Concluding Comments

Section 4 Policy-making institutional structures..364.1 Health

4.1.1 Health Care

4.1.2 Public Health

4.2 Food4.3 Physical Activity

4.4 Concluding Comment

Section 5 Policy debates and initiatives..425.1 Policy commitments5.2 Policy options5.3 Initiatives5.4 Scope and receptivity5.5 Concluding comments

Section 6 Multi-Criteria Mapping: a Methodology476.1 Introduction to MCM

6.2 Elicitation framework6.2.1 Recruiting participants and scoping6.2.2 The MCM interview


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6.3 Methods of Analysis

Section 7 Stakeholders and their Perspectives..547.1 Deciding which stakeholders or participants to include7.2 Grouping participants into Perspectives

7.3 Greek participants

Section 8 Options for Addressing Obesity.598.1 Introduction8.2 Scope of Process and Definition of Options

8.2.1 Core Options

8.2.2 Discretionary Options

8.3 Clusters of Options8.4 Engagement with Predefined Options8.5 Engagement with Additional Options8.6 Reactions in Predefined Options

8.6.1 Core Options

8.6.2 Discretionary Options

Section 9 Developing criteria ...799.1 Introduction

9.1.1 Principles

9.2 Review of the Criteria9.2.1 Nuances in the use of criteria

9.3 Grouping of Criteria into Issues9.4 Weighting process

Section 10 Appraising option performance (scoring)...9310.1 Introduction

10.2 Eliciting scores for options10.3 Appraisal of options by Issues (groups of criteria)

10.3.1 Societal benefits

10.3.2 Extra health benefits

10.3.3 Efficacy in addressing obesity

10.3.4 Economic impact on public sector

10.3.5 Economic cost to individuals

10.3.6 Economic cost to commercial sector

10.3.7 Economic cost unspecified

10.3.8 Practical feasibility

10.3.9 Social acceptability

10.3.10 Others

10.4 Diversity and uncertainty in option scoring

Section 11 Mapping option performance(rankings) .11311.1 Introduction11.2 The overall picture11.3 Final mean rankings by Participants and Perspectives

11.3.1 A. Public interest, non-governmental organisations (NGOs)

11.3.2 B. Food chain, large industrial and commercial organisations

11.3.3 C. Small food and fitness commercial organisations

11.3.4 D. Large non-food industrial and commercial organisations

11.3.5 E. Policy-makers

11.3.6 F. Public providers

11.3.7 G. Public health specialists

11.4 Final Rankings by Participants11.5 Patterns of consensus and diversity


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11.5.1 Cluster A. Exercise and physical activity-oriented

11.5.2 Cluster B. Modifying the supply of, and demand for, foodstuffs

11.5.3 Cluster C. Information-related initiatives

11.5.4 Cluster D. Educational and research initiatives

11.5.5 Cluster E. Technological innovation

11.5.6 Cluster F. Institutional reforms

11.6 Conclusions

Section 12 Process Evaluation...12712.1 Evaluation process and Results12.2 Critical Reflections12.3 Implications for Policy12.4 Conclusions

Appendices...132

References137


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Executive Summary

Rising trends in the prevalence of overweight and obesity worldwide are regarded by the

World Health Organization (WHO) as posing one of the greatest public health challenges forthe 21st century (WHO 2005). It is estimated that overweight (including obesity) affectsbetween 25-75% of the adult population in the WHO European Region. Accumulatingevidence, albeit much of it fragmentary, indicates that trends in overweight and obesityamong children parallel the global obesity epidemic among adults. Within this overall

picture the situation in Greece looks particularly alarming. Conservative estimates are that 1in 5 men and 1 in 6 women in Greece are obese and, in addition, that approximately half themen and one-third of the women in Greece are overweight. For children, consistent evidence

points to a pattern of high and rising rates of overweight and obesity starting in infancy.

As the prevalence of overweight and obesity increases, concern about the association withmorbidity and premature mortality is also increasing. Estimates of the burden of disease due

to obesity and the related direct and indirect economic costs are focusing attention on obesityas a public health problem requiring the attention of policy makers and health planners, ratherthan simply the concern of the individuals affected. Reliable estimates of the current and

projected economic and health costs of obesity in Greece are needed to inform policy actions.As it stands, the population health profile of relative longevity and low rates of non-communicable diseases has co-existed paradoxically with the rising prevalence of obesity.However, recent trends in morbidity and mortality data particularly for cardiovasculardiseases and type 2 diabetes indicates that this pattern no longer holds. Rising morbidity ratesassociated with obesity and related diseases have been accompanied by escalating health carecosts.

Trends towards more energy dense diets and sedentary lifestyles which are driving the

obesity epidemic are as apparent in Greece as elsewhere in Europe. Explanations lie in thecomplex economic and social developments affecting behavioural patterns of communitiesover recent decades. These processes are dynamic and ongoing, and require substantialchanges in public health strategies. Traditional approaches to preventing and treating obesityhave almost invariably focused on changing the behaviour of individuals, but the escalatingtrend in obesity is poignant testimony to the inadequacy of this approach. There is now a

broader consensus that reversing current obesity trends will require a better balance betweenindividual and population-wide approaches and between education-based and multi-sectoralenvironmental interventions (WHO, 2003). National and local governments and relevantinternational organisations are being called upon to respond with appropriate actions andcollaborations to counteract the rising prevalence of obesity.

Addressing obesity is a priority of the EUs Public Health Action Programme for 20032008.Identification and support of effective strategies against obesity is an important prerequisitefor community action. A wide range of different kinds of interventions could be attempted toinfluence different aspects of the production and consumption of foods and levels of physicalactivity.

A single uniform combination of policy options would not be expected to be appropriate forboth genders, for different age and social groups, or in different countries. The aims of thePorGrow project were, therefore, the exploration of the consistency and/or variability of the

perspectives of key stakeholders towards a range of different options to respond to thegrowing challenge of obesity, and the cross-national comparison of these perspectives

between nine participating member states (Cyprus, Finland, France, Greece, Hungary, Italy,Poland, Spain and the UK). A novel and powerful technique called Multi Criteria Mapping


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has been used to provide an integrative and comparative analysis of the different perspectivesof key stakeholders in nine member states on a broad range of possible types of interventions.

This report deals with findings at the national level in Greece; a report on cross-nationalfindings between nine participating member states will follow.

The PorGrow project conducted a systematic process to identify key public policy optionsthat might have a bearing on how to respond to the rising trend in the incidence of obesity inGreece. Using a Multi Criteria Mapping (MCM) method, quantitative and qualitative datawere gathered from representatives of 20 types of organisations representing relevantstakeholder interest groups. During structured interviews, stakeholders were invited toappraise a set of policy options by reference to criteria of their own choosing. They were alsoinvited to provide relative weight to their criteria, and to provide overall rankings of the

policy options in relation to each other. The research team then analysed the data gathered inthe interviews, and set the results in the context of the rising incidence of obesity in Greece,the changing patterns of food consumption and physical activity, and the current level ofdebate about policy responses to obesity in Greece.

Participants were asked to compare the performance of seven core policy options and up to13 discretionary options. They could also introduce their own additional policy options.To appraise these options, participants defined criteria, that is, the factors that they will takeinto account when evaluating those options. Participants judged the performance of eachchosen option against each of their criteria; they assigned a score for every option under eachcriterion using a linear ordinal scale of their own choosing. The higher the score the moreoptimistic the performance of the appraised option. Participants were invited to score eachoption using each criterion by reference to both optimistic and pessimistic assumptions, andto make those assumptions explicit. As a final step, participants weighted the criteria in orderof their relative importance. In this process, participants scored and ranked the options interms of their relative performance against a weighted sum of their criteria. Using a simple

formula, the scores under each criterion are multiplied by the criteria weightings to produceoverall pessimistic and optimistic relative rankings for all the options.

Multi-criteria mapping is not a procedure that can generate a proven recipe of effectiveness,but it does nonetheless provide a formula with which the challenges of obesity can sensiblybe approached. The data gathered in this study, when analyzed in the context of risingprevalence of obesity in Greece, the dominant causes and consequences and the existingpolicy framework, indicate a critical gap between need and response. We found a broadconsensus among the stakeholder representatives who participated in the PORGrow study inGreece that an integrated strategy incorporating a number of policy options would benecessary to bridge this gap. We found a broad favourable pre-disposition to implementingmeasures geared to (a) improving levels of knowledge and understanding about food, diet,

health and fitness and (b) for increasing opportunities and incentives for physical activity,with particular support for policies targeting the young. Although not generally supported,there was also significant advocacy by a few for the creation of a new government bodycharged with inter-sectoral policy co-ordination.

Educational options were considered the starting point for all the other options, withinitiatives targeting food and health education in schools in particular being the mostfavoured option. In the cluster of information-related initiatives, mandatory nutrition labellingand controls on food and drink advertising to children were ranked very poorly by the foodindustry and the advertising industry representatives, but were more optimistically evaluated

by the other participants. Physical activity oriented options were widely supported andappraised with optimism. Changes to town planning and transport policies were considered

by most to be significant long-term policies, but ranked very low primarily due to perceived


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feasibility and cost constraints. By contrast there was considerable support for improvementin communal sports facilities

Perhaps reflecting the relatively muted level of debate to date in Greece, in this enquiry wemapped consistently high rankings overall for the more classic policy options directeddownstream, offering individuals the skills, information and opportunities to make healthierlifestyle choices, rather than options geared to modifying the environment to prevent obesity.These options are familiar, relatively low cost, and likely to have social and health-related

benefits independent of their effects on obesity issues. By contrast:- CAP, when commented on at all, tended to be viewed as a given environmental/institutional constraint and reforms were not considered to be relevant to tackling obesityissues.- Controls on food composition were the most widely favoured in the cluster of options aimedat modifying the supply of and demand for foodstuffs. This was, however, most frequentlycommented on from afood safety perspective rather than in relation to the obesity- or health-

promoting properties of ingredients in processed foods.- In a similar vein, technical fix options for tackling obesity (increased use of synthetic

sweeteners and fat substitutes, medication to control weight) received scant attention and,when commented on at all, were not considered relevant.- Controls on food supplies through controlling sales of food in public institutions met withmixed evaluations, primarily in terms of social acceptability and efficacy.- Fiscal measures (taxes and subsidies) designed to modify consumer buying behaviour were

poorly evaluated by most participants also on the grounds of social acceptability and alsoefficacy. Pricing tactics were considered to have a very low impact on peoples dietary

patterns and lifestyle choices.

In conclusion: in Greece the case for action on obesity as a public health concern is only nowbeing made, the level of debate on policy options is muted to date, and obesity is incidental tothe public health agenda and institutional reforms recently initiated. On a more optimistic

note, there are signs that the accelerating momentum concerning policy responses at aEuropean level is meeting with a response in Greece. The considered opinions of experts,stakeholders and policy-makers are critical in informing decision-making on appropriate

policy responses to obesity. As such the MCM method provides a novel means of capturingand comparing these evaluations. The PorGrow analyses thus point to support for a portfolioof measures to combat the problem of obesity in Greece as well as an appreciation that

political will is an essential pre-requisite.


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1

Rising trends in the prevalence of overweight and obesity worldwide are regarded by theWorld Health Organization (WHO) as posing one of the greatest public health challenges forthe 21st century (WHO 2005). It is estimated that overweight (including obesity) affectsbetween 25-75% of the adult population in the WHO European Region. Accumulatingevidence, albeit much of it fragmentary, indicates that trends in overweight and obesityamong children parallel the global obesity epidemic among adults (WHO 2000).

Within this overall picture the situation in Greece looks particularly alarming, withprevalence rates for overweight and obesity which top the charts in international andEuropean league tables for both adults and children. Recent high profile publications for theEU Platform for Action on Diet, Physical Activity and Health (IOTF/IASO 2005) and theEuropean Commissions Green Paper (2005) show a prevalence of overweight and obesityamong men (78.6%) and women (74.7%) in Greece which is the highest reported for all 25EU countries. Greek children and teenagers share a similar dubious distinction, reported ashaving among the highest rates of overweight and obesity (over 30%) compared with childrenin other European countries (ibid).

International comparisons such as these are invaluable in focusing attention on the seriousnature of the problem in Greece. A basic limitation is, however, that these league tables aregenerated using surveys of various designs, periods, and methods.1 Indeed, the WHO and theIOTF have highlighted the lack of nationally representative data in many countries as amajor obstacle to a more accurate assessment of the scale and trends of the obesity epidemic (WHO 2000; IOTF 2005).

For Greece, there is no nationally representative survey data equivalent to the US NHANESor the UK regional surveys (England, Scotland, Wales, and N. Ireland). Estimates of theprevalence of overweight and obesity in the Greek population therefore rely on unofficialsources, primarily surveys reported in scientific journals. The reliability, validity andcomparability of existing prevalence data for Greece are thus complicated by heterogeneousstudy designs, differences in the survey populations and, critically, by whether the BMIcalculations (see box) were based on self-reported weight and height data or obtained throughdirect physical examination. Self-reported height and weight data are valid for identifyingrelationships in epidemiological studies but, particularly where no validity sub-study has beenconducted, are liable to underestimate the problem (Spencer et al. 2002; Brener et al 2003;Gillum & Sempos, 2005).

We review here the data available for assessing the prevalence and trends of overweight andobesity among adults and children in Greece.

1 The IOTF clearly states these limitations in all publications and underlines the point that with the limited dataavailable, prevalence rates are not standardized. Unfortunately this cautionary note on interpretation is rarelyreproduced in press reports or in secondary citations in scientific papers.


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2

Obesity is defined as abnormal or excessive fat accumulation to the extent that health may beimpaired (WHO). Various measures are used to estimate overweight and obesity, withcorresponding threshold values calculated to reflect adiposity and to be related to morbidityoutcomes. For adults, the most common is the Body Mass Index (BMI), which measuresweight relative to height (kg/m). This correlates fairly well with body fat content in adultsbut it is only an approximation of adiposity, because an adult with high levels of lean(muscle) mass will also have arelatively high BMI score. Various(BMI) cut-off points have been usedto classify normal and overweight

or moderate obesity. The mostwidely used is the classificationadopted by the World HealthOrganization (see box) wherebyoverweight is defined as BMI 25.0-29.9kg/m and obesity as BMI 30kg/m. These standard definitions aremainly derived from populations ofEuropean descent (WHO 2000) anddifferent thresholds have beenproposed for other populations (egfor Asian populations the lower

threshold of BMI 23 is proposed(IOTF 2005).

Measures of fat distribution, notably waist circumference and waist-to-hip ratio, are used inassociation with/or instead of BMI because the distribution of fat affects the risks associatedwith obesity. That is, increases in abdominal fat pose a greater risk to health than increases infatness elsewhere. These measures of central adiposity (see box) are increasingly being usedto calculate the risk of obesity co-morbidities. For survey purposes, however, BMI is themain measure of overweight and obesity currently used (Molarius et al,1999).

Figure 1 (Appendix Table 1A) shows the differences in prevalence of overweight and obesityin men and women in Greece as assessed by major national and sub-national/regional surveysconducted after 1990.

The widely cited IOTF data for Greece of obesity prevalence of 27.5% in men and 38.1% inwomen are based on the major survey conducted throughout Greece in the mid-1990s as partof the European Prospective Investigation into Cancer and Nutrition (EPIC) (unpublisheddata). The Greek EPIC cohort comprised healthy volunteers recruited from the generalpopulation and intentionally included a high proportion of women; i.e. it was not designed asa nationally representative sample. It does, however, provide the largest available data set

Adiposity classifications for adults

BMI (kg/m).

Underweight


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3

using direct standardized measures by trained personnel. The picture of epidemic levels ofoverweight and obesity is documented in published data on mean BMIs for men (28kg/m)and women (26.5 kg/m at 30 kg/m >45-y) (Trichopoulou et al

2000; Trichopoulou et al 2005). Detailed analyses of prevalence data published for the 50-64y age bracket show results which parallel the overall IOTF estimates, with amazingly highcombined overweight and obesity rates of ~ 80% for both men and women, and with theprevalence of obesity being much higher in women (42.6%) than in men (29.9%)(Haftengerger et al. 2002).

FIGURE 1: Prevalence of overweight and obesity among adults in Greece according to

4 surveys

Men

0

10

20

30

40

50

60

70

80

90

IOTF ATTICA HMAO Crete

>30 25-29,9

Women

0

10

20

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40

50

6070

80

90

IOTF ATTICA HM AO Cre te

>30 25-29,9

A similar cumulative prevalence of overweight and obesity for men (73%) is reported in the

ATTICA survey, a smaller but representative random sample for the Attica region of Greece,including Athens (Panagiotakos et al 2004). For women, however, the ATTICA Study showsa much lower cumulative prevalence of overweight and obesity (46%); a gender differencewhich is in line with most other European countries. Recent analysis of epidemiologicalsurvey data for Crete also show the same gender difference (63% in men compared with 39%in women), but lower prevalence levels of overweight and obesity in adults in thissouthernmost region of Greece (Linardakis, 2005).

Data from a nationwide cross-sectional study conducted by the Hellenic Medical Associationfor the Obesity (HMAO) have recently been made available (HMAO, 2004). This shows thesame pattern of higher cumulative prevalence rates for Greek men (67%) compared withGreek women (48%). The scale of the problem overall is similar to that assessed by theATTICA Study although it is interesting to note that the prevalence of obesity recorded in theHMAO survey is higher than both the ATTICA and Crete regional studies, even although theHMAO prevalence rates are derived from self-reported anthropometric measurements(HMAO 2006).2 Conversely, Eurostat data for Greece, based on the Eurobarometer self-report surveys, give a significantly different picture of the scale of the problem, underliningthe need for caution in interpreting prevalence rates derived from self-reported data. Thus theEurostat data for Greece for 1996 and for 1998-2001 (BMI 27 for between 29-30% of adultsin Greece) collated in the same period as the EPIC, ATTICA and HMAO surveys, show

2 This may in part reflect the sampling procedure: the HMAO conducted a school-based national survey todetermine obesity prevalence in children, and the adults comprise parents/guardians selected via the school clustersampling. They were asked to weigh and measure themselves, rather than simply report height and weight.


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significantly lower prevalence rates even allowing for differences in the Eurostat cut-offpoints (BMI 27kg/m). It does, however, reflect a similar pattern insofar as the prevalence ofoverweight among adults in Greece is among the highest in the EU, and well above the EU-

15 average. The Eurostat data also show higher prevalence of overweight in men (34.9%)compared with women (29.4%) (Eurostat 2002).

Analyses of age-and gender-related prevalence data for the different surveys are shown inFigure 2a-c. These analyses show a similar general pattern whereby BMI increases steadilywith age, and the prevalence of obesity is higher in men than in women up until late middle-age (~50-y). Thereafter obesity rates tend to be higher in older women than in older men, andthe Greek EPIC and ATTICA data show the upward trend in obesity prevalence peaking at alater age in women.

Data from the Greek EPIC cohort show a steady rise in prevalence of obesity among men,peaking in the 55-64y age range (32.7% obese and 51.2% overweight) whereas for womenprevalence rates overtake men in the 45-54y age group (37.9% for women compared to 29%for men) and the increasing trend for women peaks in the 65-74y age group (a staggering53.4% classed as obese and 36% overweight) (Trichopoulos et al 2003). The HMAO surveyand the ATTICA survey show a similar pattern, but the ATTICA Study reports significantlylower rates of obesity for both men and women in all age groups, and shows the age-specificpeak prevalence of obesity in men between 40-59 years old and in women between 50-59years old (Panagiotakos et al 2004).

Limited data on the severity of obesity are provided in the ATTICA Study, which show that16% of men and 11% of women were moderately obese (Class I:BMI 30-34.9 kg/m), and94cm in men& >80cm in women). Cross-sectional analysis of a representative sample of Greek adults(n=9669) designed to assess prevalence of the metabolic syndrome (the MetS-GreeceMulticentre study) shows a higher prevalence based on direct measurement: 56.8% of thegeneral population were characterized by abdominal obesity at WC action level 2 (>102cm in

men and >88cm in women) (Athyros et al, 2005).


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FIGURE 2: Prevalence of overweight and obesity in Greek adults by age and gender

Fig 2a : Greek EPIC cohort

Me n

0

10

20

30

40

50

60

25-34 35-44 45-54 55-64 65-74 75+

Overw eight Obese

Women

0

10

20

30

40

50

60

25-34 35-44 45-54 55-64 65-74 75+

Overweight Obese

Source:Trichopoulos et al. 2004.

Fig 2b : HMAO

Men

0

10

20

30

40

50

20-30 31-40 41-50 51-60 61-70

Overw eight Obese

Women

0

10

20

30

40

50

20-30 31-40 41-50 51-60 61-70

Overweight Obese

Source: Hellenic Medical Association for Obesity (HMAO)

Fig 2c: The ATTICA Study

Men

0

10

20

30

40

50

60

70

20-29 30- 39 40-49 50- 59 >60

Overw eight Obese

Women

0

10

20

30

40

50

60

70

20-29 30-39 40-49 50-59 >60

Overweight Obese

Source: Panagiotakos et al. 2004

[Data in Appendix Table A2]


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A recent analysis of trends in lifestyle-related risk factors in Europe reported that intra-

national differences in certain factors, including obesity, surpass international differences(van der Wilk and Jansen 2005). The WHO (2005) has also reported that obesity and relateddiseases are among the most unevenly distributed health conditions, and that there is a trendtowards increases in differences between social classes. There is, however, a dearth ofreliable data to ascertain whether and/or to what extent this applies in Greece. Fragmentsfrom available analyses of the distribution of several socio-demographic and lifestylecharacteristics of survey participants according to their BMI classification has shown inverseassociations between obesity status and years of education (Trichopoulou et al 2005) and bysocio-economic status (Manios et al 2005). The ATTICA Study has reported urban-ruraldifferences in prevalence rates, but these were no longer significant when the higherprevalence of physically active occupations in the rural areas was taken into account(Panagiotakos, 2004). Albeit varying in size, design and significance, a number of studies

document overweight and obesity in particular age groups and occupations (Mamalakis andKafatos 1996), including military personnel (Mazokopakis et al 2004), and Universitystudents (Bertsias et al 2003). Together with localized surveys (Gikas et al 2004), and gender-specific studies (Nassis and Geladas, 2003), these reinforce the observed pattern of highprevalence rates of overweight and obesity among adults in Greece. For religious and ethnicminorities there are no data apart from the MetS-Greece survey, which shows that prevalenceof abdominal obesity is higher in Greek Muslims than the general population (63.6% vs56.8% respectively) (Athyros et al 2005). Apart from indigenous minorities (Muslim,Romany), this lack of documentation is of particular concern given the burgeoning growth ofnewly rooted migrant ethnic communities throughout Greece over the last decade.

Available data from the Seven Countries Study in the 1960s show the BMIs of middle-agedmen were only 22.8 and 23.3 in Crete and Corfu respectively (Dontas et al, 1998). At thisstage there were only 2-5% obese men and 20-22% overweight. Low prevalence of obesitywas a feature of the Mediterranean region in those years, partly explained by relatively highphysical activity levels (Ferro-Luzzi et al 2002). Studies of adults in Crete (Kafatos et al,1991;1997), and Athens (Moulopoulos 1987) provide benchmarks against which to documentthe dramatic increase in the prevalence of overweight and obesity. While the data are toolimited to determine the precise trajectory of the rising trend, Greece would appear to be wellwithin the WHO observation that the prevalence of obesity has risen three-fold or more inmany European countries since the 1980s. The WHO prediction of future trends is not

reassuring, estimating that while the prevalence in the European Region is expected to rise byan average of 2.4% in women and 2.2% in men over five years, some countries might show afaster increase with Greece being listed alongside Finland, Germany, Sweden and the UKas one of the countries where the rate for men can be expected to rise more rapidly (WHO2005).

Interpretation of available prevalence data is complicated and requires caution. Thus, higherprevalence rates of obesity in women compared with men cited in international comparisons(IOTF) is not supported by other available surveys of adults in Greece. Yet this lack of


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agreement as to gender differences in cumulative prevalence rates may be more apparent thanreal, the product of differences in study design and the high proportion of older adults in theGreek EPIC cohort (~70% >45y). Similarly, as illustrated in Figure 3, even the same data

classified by (slightly) different age-range categories and an extended age range can give adifferent impression. Such a difference could be critical, for example, if one were looking atpolicy options targeting older citizens.

As it stands, being based on a representative random sample, the relatively conservativeprevalence rates reported in the ATTICA Study provide the best available estimate of thecurrent position in Greece: roughly one in five men and one in six women obese. In addition,approximately half of the men and one-third of the women were found to be overweight.Based on the recent (2001 census) age-sex distribution of the Greek population, the ATTICAStudy investigators speculated that 2.4 million men and 1.4 million women are overweight,and 900,000 men and 675,000 women are obese (Panagiotakos et al 2004).

FIGURE 3: ATTICA Study: prevalence of obesity (BMI30 kg/m ) by age and gender

(a) Panagiotakos et. al. 2004 and (b) for WHO Global InfoBase

(a)

0

5

10

15

20

25

30

20-29 30-39 40-49 50-59 >60

Men Women

(b)

0

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35

18-34 35-44 45-54 55-64 65-74 75-89

Men Women

Studies examining trends in childhood obesity suggest that it has increased steadily in Europeover the past two to three decades (Lobstein et al, 2004). For Greece, there are insufficientdata available on temporal changes to date to determine trends. The few longitudinal andcross-sectional regional studies available, however, do indicate that the prevalence ofoverweight and obesity has been increasing in the last decades, especially among boys(Mamalakis & Kafatos 1996; Mamalakis et al, 2000; Krassas et al 2001; Magkos et al 2005).

Recent reports indicate that the prevalence of overweight and obesity among children andadolescents in Greece is now among the highest in Europe (IOTF 2005). This is of particularconcern given the vast body of evidence which is amassing on the short term healthconsequences of childhood obesity and the multiple adverse effects tracking through tomorbidity and mortality in adulthood (Reilly et al, 2003; Deckelbaum et al, 2001;Engeland etal. 2004; Goran, 2001), in particular the rising rates of type 2 diabetes and other co-morbidities characterizing the metabolic syndrome.


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Difficulties in assessing prevalence of overweight and obesity in adults are compounded inchildren by the variations in criteria used. Simple BMI is inappropriate because it does nottake into account the changing weight and height in the growth curves of children and

adolescents. Various reference values are thus used to define overweight and obesity inchildren and adolescents. Up until recently, most surveys used the US CDC or NHANESgrowth charts (which use the 85th and 95th percentiles as the cut-offs for overweight andobesity respectively) and/or population-specific reference values. Since 2000, the age andgender-specific BMI cut-off points adopted by the IOTF of childhood equivalents ofoverweight (BMI 25-29.9) and obesity (BMI 30) in adulthood have been widely used as thebest available basis for international comparisons (Cole et al 2000; Lobstein et al 2004).Some caution is necessary in interpreting the terms used for prevalence. Some studies usingthe IOTF criteria refer to pre-obese as the classification of childhood equivalence to BMI25-29.9 and overweight as equivalence to BMI 25 (ie including obese BMI 30). Unlessotherwise stated, this review uses overweight to mean BMI 25-29.9.

Waist circumference and waist-to-height ratio are posited as better predictors of obesity co-morbidities in children than BMI (McCarthy & Ashwell 2006; Savvas et al, 2000.) but thereare no standard cut-off points currently in use and the data is relatively scarce.

The WHO collaborative survey Health Behaviour in School-aged Children (HBSC)provides cross-sectional nationally representative surveys of children and adolescents aged11-16y based on self-reported data and questionnaires. Analysts of the HBSC survey for2001-2 reported enormous variation (3-34%) in the prevalence overweight (includingobesity) across the 35 countries and regions included in the 2001-2 survey. For Europe thehighest prevalence is reported for the UK regions, followed by Greece, Italy, Malta, Portugaland Spain (Mulvihill et al, 2006). The smaller 1997-8 survey (involving 13 Europeancountries) reflects the same pattern, with highest rates reported for Ireland, Greece andPortugal (Lissau et al 2004).

The HBSC surveys for Greece, as for most other countries, show marked gender differences,with the prevalence of overweight and obesity being much higher in adolescent boys.Comparative analyses by gender with the WHO Eur-A3 group of countries shows prevalenceof overweight and obesity among 15y boys in Greece (20.3% and 2.7% respectively) to behigher than the Eur-A average of 13.1% overweight and 2.5% obese, whereas prevalence

among 15y girls in Greece (7.5% overweight and 1.1% obese) was somewhat lower than theEur-A average of 7.6% overweight and 1.5% obese (WHO 2006).

3 The 27 European countries with very low child mortality and very low adult mortality, designated Eur-A byWHO comprise: Andorra, Austria, Belgium, Croatia, Cyprus, the Czech Republic, Denmark, Finland, France,Germany, Greece, Iceland, Ireland, Israel, Italy, Luxembourg, Malta, Monaco, the Netherlands, Norway, Portugal,San Marino, Slovenia, Spain, Sweden, Switzerland and the United Kingdom. However, data for most indicatorsare unavailable for Andorra and Monaco. Therefore, unless otherwise indicated, averages for Eur-A refer to the 25countries for which data are available.


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For 2001-2, prevalence of overweight (including obesity) in 13y and 15y boys was 20.3%and 23% respectively, compared with 12.1% and 8.6% in 13y and 15y girls respectively.

Similarly, detailed analyses available for the 1997-8 survey in Greece, which involved 4299

children and adolescents, show 9.1% of all girls and 21.7% of all boys classified asoverweight, with corresponding values for obese girls and boys of 1.2 and 2.5% respectively(Karayiannis et al, 2003).

A second major recent study examining the prevalence and trends in childhood obesity is thewidely cited IOTF comparative review of a number of surveys conducted in Europeancountries using direct measurement methods (Lobstein et al, 2004; Lobstein and Frelut,2003). This report showed the highest prevalence (>30%) of combined overweight andobesity among children aged 7-11y in the Mediterranean South: Italy, Malta, Spain, Greeceand Cyprus. Among adolescents (14-17y) in these Mediterranean countries the incidence ofoverweight is much lower (~20%), comparable to reported rates for adolescents in Britain,but still higher than their counterparts elsewhere in Europe.

For Greece the IOTF data are derived from two regional studies: (a) a cross-sectional surveyconducted in 2001-2 in the city of Thessaloniki, Northern Greece (Krassas et al 2001), and(b) a longitudinal study in Crete initiated in 1992, involving (2) smaller cohorts of schoolchildren (263 boys and 278 girls) from 6y to 16y (Manios et al 2002; Kafatos et al 2005).Figure 4 compares the available prevalence data from the Thessaloniki survey (n= 2,458), arecent evaluation of epidemiological data available for children and adolescents in Crete(n=1,209) (Linardakis 2005) and also the national survey data recently made available by theHMAO (n=18,045)(HMAO 2004). All studies use school cluster sampling and prevalencerates are derived from direct measurement data.

FIGURE 4: Prevalence of overweight and obesity among children and adolescents in

Greece according to 3 (direct measurement) surveys

6,9

11,712,7

29

26,6

20,7

27,9

25,3

11,2

7,6

10 9,7

6,5

8,9

13,7

3,74,9

16,3

11,1

25,3 25

12,5

20,1

1311,4

4,7

7,2

13,8

53,6

6,3

1,5

0

5

10

15

20

25

30

35

HMAO 2-

6yrs

Crete 3-6yrs HMAO 7-

12yrs

Crete 7-

12yrs

Thessaloniki

6-10yrs

HMAO 13-

19yrs

Crete 13-

18yrs

Thessaloniki

11-17yrs

Boys Overweight Boys Obese Girls Overweight Girls Obese

[Data in Appendix Table A3]


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The high prevalence of overweight and obesity shown for very young children 90th percentile) in boys and girls in Crete is on a par with the USA.

The available data thus suggest significant regional variations in the prevalence of obesityamong children and adolescents in Greece. North/south regional variations (in growthcurves) have been documented in Italy (Cacciari et al 2002). Whether the variations observedbetween studies in Greece to date are a function of study design or measurement sensitivity orsocio-demographic factors impacting on regional susceptibility to obesity has yet to bedetermined. Similar reservations apply to available data on gender and age-related trends.

There is, nonetheless, consistent evidence indicating a pattern of high and rising rates ofoverweight and obesity starting in infancy, with higher levels of overweight and obesityamong children compared to adolescents. There is also converging evidence indicating thatthe prevalence of obesity as defined by BMI is consistently higher in adolescent boyscompared to girls.

Despite the piecemeal and fragmented nature of existing survey data in Greece, there is nodoubt that the problem of overweight and obesity among adults and children in Greece isserious and appears to be getting worse. The rapidity of this development in Greece within

the space of less than a generation presents an enormous public health challenge. Yet tochannel concern into effective policy requires reliable and comparable public healthindicators. The IOTF (2005) call for adequate monitoring and surveillance systems to ensurerealistic assessment of the prevalence and trends in the obesity epidemic has a particularurgency in Greece. It is, in short, a critical requirement for sound health policy and effectivepolicy interventions.


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Summary of main points in section 1

Greece is regularly shown to top the charts of international and European league tablesof obesity prevalence among adults and children. Existing survey data indicates that the problem is serious and appears to be getting worse. Conservative estimates are that 1 in 5 men and 1 in 6 women in Greece are obese and, in

addition, that approximately half the men (2.4m) and one-third of the women (1.4m) inGreece are overweight.

Albeit fragmentary, for children there is consistent evidence pointing to a pattern of highand rising rates of overweight and obesity starting in infancy; higher levels of obesity inchildren compared with adolescents; and a higher prevalence of obesity among adolescentboys compared with girls.

The rapidity of these developments presents enormous public health challenges.

Not least of these is the need for adequate monitoring and surveillance systems to

accurately assess the dimensions of the problem and also to enable effective policyresponses.


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As the prevalence of overweight and obesity increases, concern about the association withmorbidity and premature mortality is also increasing. Estimates of the burden of disease due

to obesity and the related direct and indirect economic costs are focusing attention on obesityas a public health problem requiring the attention of policy makers and health planners,rather than simply the concern of the individuals affected. This section considers theseestimated human and financial costs and how they may be impacting on the health profileand pockets of the Greek population.

Overweight and obesity are associated with adverse metabolic effects on blood pressure,cholesterol, triglycerides and insulin resistance: a clustering of complications known as themetabolic syndrome. As such excess weight gain, and particularly abdominal obesity, is alsoone of the key risk factors for a number of chronic diseases.

A vast body of evidence is accumulating on the pathology and health consequences ofobesity among children and adults. Recent reviews (WHO, 2002; Lobstein et al, 2004)identify the non-fatal but debilitating health problems associated with obesity to includerespiratory difficulties (sleep apnoea and asthma), chronic musculoskeletal problems(including osteoarthritis), and endocrine disorders (including polycystic ovarian syndromeand infertility). The more life-threatening illnesses associated with obesity are:

- cardiovascular diseases (CVD), including coronary heart disease, andcerebrovascular diseases (hypertension, stroke);

- non-insulin-dependent diabetes (NIDDM or type 2 diabetes);

- certain cancers, especially the hormonally related (endometrial, breast) and large-bowel (colon) cancers, and- gallbladder disease.

All these conditions become more prevalent with age and are also more prevalent amongoverweight people. This translates into an escalation of the burden of ill-health from obesitywith age (Lean, 2000; WHO 2002).

Non-communicable diseases (NCDs) such as these are multi-causal and now account for thebulk (>80%) of morbidity and mortality in most developed countries, including Greece.Quantifying the links between obesity and the diseases with which it is associated therefore

present complex methodological challenges. That is, there are inherent (statistical)

uncertainties due to the number of assumptions needed to calculate the relative risk ofobesity as a causal/contributory factor, and also due to the limited nature of the dataavailable (prevalence, morbidity, mortality) for estimating the burden of disease attributableto overweight and obesity4.

In terms of relative risk: Table 2.1 presents the best available estimates of the extent towhich obesity increases the risks of developing major chronic diseases relative to the non-obese population. These estimates, compiled for the UK National Audit Office, are based on

4 The attributable fraction shows that the burden of disease caused by any risk factor is a function of the

prevalence of that risk factor and the magnitude of its causal association with disease, expressed as relative risk.The methodological issues involved in these calculations are reviewed briefly by Mark (2005) and in detail byMathers & Loncar, 2005.


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a comprehensive review of international (primarily North American) studies and give abroad indication of the strength of the association between obesity and the main diseasetypes (NAO, 2001). In addition to increasing the risk of ill-health, obesity increases the riskof mortality at any given age. Evidence suggests that for young adults in general the risk of

premature mortality (


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Greece, 7.4% of the total burden of NCDs (in DALYs) is considered attributable specificallyto overweight (6.9% for men and 8.1% for women) (WHO 2002). There is evidently aninter-relationship between the WHO risk factors. For example, elevated blood pressure andelevated cholesterol, each of which is an independent risk factor for CVD, can also be causedor aggravated by weight gain. According to these estimates, overweight and its co-morbidities together exceed the burden of ill-health linked to tobacco and, with dietaryinadequacies and physical inactivity, account for approximately one-third of the total disease

burden (in DALYs) in developed economies.

Table 2.2 Burden of disease measured in DALYs (%)

attributable to selected risk factors

Risk factors Total DALYs (%)

Tobacco 12.2

Blood pressure 10.9

Alcohol 9.2

Cholesterol 7.6Overweight 7.4

Low fruit and vegetable intake 3.9

Physical inactivity 3.3

Illicit drugs 1.8

Unsafe sex 0.8

Iron deficiency 0.7

Source: WHO, 2002

At first glance, the rising prevalence of overweight and obesity in Greece has not had areadily discernible impact on the health profile of the population. Indeed, along with othercountries in Southern Europe, Greece continues to enjoy an enviable reputation for longevityand health that is associated with the beneficial health properties of the Mediterranean diet(to be discussed in Section 3). As such, commentators continue to point out that in Greeceand other Mediterranean countries the absolute risk of obesity-related diseases such ascardiovascular disease is among the lowest in Europe (Kromhout, 2001; Haftenberger et al,2002). This apparent paradox warrants a closer look at the population health data.

Life expectancy at birth has continued to increase steadily in Greece and now stands at

75.8y for men and 81.1y for women (WHO 2006).6

Absolute gains in the last 20 years(~3years) have been smaller than other EU countries. Although male life expectancy (at birthand at 65y) in Greece continues to rank among the highest in Europe, womens lifeexpectancy, from well above the EU average at the beginning of the 1970s, has remained ator below the EU average from the 1980s onwards. This is attributed primarily to relativedeterioration in womens life expectancy at 65y (with the SDR for CVDs in women inGreece >65y being markedly higher than the EU average). The net effect, as shown in Figure2.1, is that Greece has lost its leading position and since 1995 life expectancy at birth has

been at or below the EU-15 average, whereas LE at 65y has been below the EU-15 averagesince the late 1980s.

6 According to WHO estimates Greeks, on average, can expect to be healthy for about 90% of their lives. On

average Greeks lose 7.4y to illness the difference between LE and healthy life expectancy (HALE). Sincewomen live longer than men, and the likelihood of deteriorating health increases with age, women lose morehealthy years (8.2y) than men (6.7y) WHO (2003):


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Greece EU members before May 2004 EU members since May 2004

Source:WHO/Europe, European HFA Database, January 2006

The extent to which this relative deterioration in LE is associated with the obesity epidemicis a matter of conjecture (considering the numerous factors affecting LE as well as the lackof evaluative studies in Greece). Given the evidence of increased risk of mortality associatedwith obesity, an effect cannot be ruled out. It is worth noting in this respect that in the UKthe average loss of life attributable to obesity has been estimated to be over two years oncurrent UK life expectancy statistics and is expected to rise to over five years as healthy lifeexpectancies increase faster for normal weight than for obese people (UK Department of

Health 2005).

As in other European countries, cardiovascular diseases (CVD) are the biggest single causeof death, accounting for 49% of all deaths in Greece in 2001 (WHO, 2006). CVDs areassociated with age in that nearly nine out of ten deaths of this type occur in persons aged65y or over (Eurostat 2004). As shown in Figures 2.2 and 2.3, the last 25-30 years havewitnessed a relative deterioration in mortality rates in Greece from all CVDs from among thelowest in Europe to around the EU average for ischaemic heart disease, to well above theEU average for cerebrovascular diseases (hypertension, stroke). CVD mortality rates inGreece are now considerably higher than in other Mediterranean populations (Italy, Portugal,Spain). Specifically: premature mortality rates (


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Fig 2.3b SDR, Cerebrovascular diseases,

all ages per 100.000





Cancers are the second main cause of death in Greece, accounting for 25% of all deaths. Asshown in Figure 2.4, overall cancer mortality rates are consistently below the EU average,and this also applies to cancers linked with obesity (female breast cancer and colon cancer).The notable exception is death rates for cancer of the lung, which have been rising steadilyfor both sexes and are well above the EU average. This is linked directly with the very high

prevalence of cigarette smoking in Greece (>33% adults) (OECD 2005).

Fig 2.3a SDR, Cerebrovascular diseases,

0-64y, per 100.000

Fig 2.2a SDR, Ischaemic Heart

Disease, 0-64y, per 100.000

Fig 2.2b SDR, Ischaemic Heart

Disease, all ages per 100.000


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Interpreting changes in mortality rates as functions of risk factors or the features of healthcare systems requires caution, including consideration of the reliability and comparability ofdeath certification practices (Eurostat, 2004). Even so, the data warrants serious concerninsofar as trends in CVD in Greece the primary killer and also the leading cause of deathamong the obese do not match the decreasing trend in age-adjusted cardiovascular disease

mortality observed in the USA and in most other Western European countries.

Recent analyses of secular trends in cardiovascular disease risk factors according to BMI forUS adults (based on NHANES surveys from 1960-62 through to 1999-2000) concluded that,with the important exception of diabetes, the prevalence of high cholesterol, high blood

pressure and smoking have declined significantly over the past 40 years in all BMI groups(Gregg et al, 2005). The NHANES analysts noted that although obese persons still havehigher risk factor levels than lean persons, the levels of these risk factors are much lowerthan in previous decades (ie obese persons in the US now smoke less and have lowercholesterol levels and lower blood pressure). These changes in risk factors have beenaccompanied by increases in lipid-lowering and anti-hypertensive medication use,

particularly among obese persons (ibid). These results, which indicate that the relationship

between obesity and its co-morbidities is not necessarily constant, are consistent with theincrease in life expectancy and the declining mortality rates from ischaemic heart disease inthe USA (Mark 2005), despite the increasing prevalence of obesity, and may have a bearingon the mortality rate in Greece.

For Greece, the relatively static mortality rates for ischaemic heart disease and slackerdownward trend in cerebrovascular disease mortality have been accompanied by anescalating burden of clinical care, as indicated by hospital discharges associated with these

primary cardiovascular diseases (Figure 2.5). Moreover, an increasing number ofcardiovascular patients is expected because of the ageing of the population (Kromhout,2001), and this is likely to be compounded by age-related trends in obesity and its co-morbidities. Available evidence on the prevalence of CVD risk factors indicates that a high

proportion of adults in Greece are at risk (Pitsavos et al, 2003; Efstrapopoulos et al, 2006;Gikas et al 2004). The best available nationally representative survey, the MetS-Study

Fig 2.4a SDR, Malignant Neoplasms, 0-

64y, per 100.000

Fig 2.4b SDR, Malignant Neoplasms,

all ages, per 100.000


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(Athyros et al, 2005), reports an age-standardized prevalence of the metabolic syndrome* of23.6% among Greek adults (with rates being similar in men and women). As to be expected,

prevalence increases with age in both sexes (4.8% in the 19-29y age group and 43% for thoseover 70 years old), and the most common abnormalities for both men and women areabdominal obesity and hypertension. Based on the 2001 Census, the Met-S analysts estimatethat about 2.3 million Greeks may have the metabolic syndrome (ibid).



Better health care and medication can be expected to mitigate the consequences of CVD interms of morbidity and premature mortality, but it is as yet unclear whether such gains will

be offset by the increasing prevalence of obesity among children and adolescents. That is,there is concern that younger age of onset of obesity may result in longer duration of obesitythroughout life, which may increase obesity-related morbidity and mortality (Mark, 2005).Existing evidence indicates that cardiovascular risk factors are now being routinely detectedamong Greek school-children and adolescents, with worrying implications for their futurehealth (Magkos et al,2005; Bouziotas et al, 2004; Manios et al 2004; Manios et al 2005).Particular concern is focusing on the appearance of type 2 diabetes, previously known as

adult-onset diabetes, among obese children and adolescents.

Non-insulin-dependent / type 2 diabetes, which is rapidly becoming one of the major non-communicable diseases in Europe, is arguably the most insidious medical consequence ofobesity. As one expert analyst has aptly summarized, it is increasingly common, has seriouscomplications, is difficult to treat, reduces life expectancy by 8-10 years and is expensive tomanage (Astrup, 2001). It is estimated that approximately 85% of people with diabetes areType 2, and of these over 90% are overweight (WHO 2006), In turn, the metabolicabnormalities underlying type 2 diabetes predispose to hypertension and CVD.

* Metabolic syndrome is considered present with at least 3 of the 5 identified risk factors; i.e. abdominal obesity,hypertriglyceridaemia, low HDL-cholesterol, high blood pressure and high fasting glucose.

Fig 2.5a Hospital Discharges,

Ischaemic Heart Diseases per 100.000

Fig 2.5b Hospital Discharges,

Cerebrovascular diseases per 100.000


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For Greece, the most recent estimated prevalence for 2003 is 6.1%, projected to rise to 7.3%by 2025 (IDF 2003, EC Commission 2006). WHO estimates in terms of numbers point to853,000 affected in 2000 rising to over one million people (1,077,000) in Greece by 2030(WHO 2006). The recent ATTICA Study, however, indicates that the prevalence of type 2diabetes already exceeds predictions at 7.8% of men and 6% of women (Pitsavos et al,2003). Moreover, as shown in Figure 2.6, there is a steep age-related increase in prevalencein men and women over 55 years of age.

Fig 2.6 Diabetes Prevalence in Greece by age group

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

18-34 35-44 45-54 55-64 65-74 75-89

Men (n=1416)

Women (n=1407)

Source:ATTICA Study data as supplied to the WHO (2006)

The myriad other disabilities and debilitating conditions associated with obesity are

recognized as having a strong negative impact on health status and quality of life, but there isinsufficient data available to assess these human costs. As it stands, the current and projected

burden of disease in Greece caused by the primary life-threatening conditions associatedwith obesity leave scant room for complacency.


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As shown in Figure 2.7, developments in the health profile of the Greek population havebeen accompanied by rising health care costs, which in 2003 totalled 9.9% of GDP (OECD

2005). Public expenditure accounts for just over half of total health care expenditure inGreece (51.3% in 2003) (OECD 2005), making the proportion of health care costs borne byprivate expenditure among the highest in Europe (WHO 2006). Pharmaceutical expenditureis also relatively high, accounting for ~16% of total health expenditure (OECD 2005).



Growth in health spending can be attributed to several factors (ibid). Advances in thecapability of medicine to prevent, diagnose and treat health conditions are a major factordriving health cost growth. Population ageing also contributes to the growth in healthspending, as does obesity. Estimates from the United States indicate that the cost of healthcare services is 36% higher and the cost of medications 77% higher for obese people than for

people of normal weight (Sturm, 2002), and that these costs grow disproportionately largefor the severely obese (Andreyeva et al, 2004; Raebel et al, 2004). As regards the cost

burden at national level, reflecting the lack of authoritative evidence on the prevalence andhuman costs of obesity in Greece, the extent to which total health care costs can be attributedto obesity is not known. Estimates made for other countries, however, indicate that they may

be substantial.

Recent analyses by the UK National Audit Office (NAO 2001) lists the direct costs ofobesity as arising from medical consultations, including hospital admissions, and the cost ofdrugs prescribed (a) for treating obesity itself and (b) for treating diseases attributable to

obesity. Using 1998 figures for England, the NAO estimated the direct costs of treatingobesity to be 9.4 million at 1998 prices, mainly due to the cost of consultations with generalpractitioners. The cost of treating diseases attributable to obesity was estimated to be 469.9

Fig 2.7 Total health expenditure as % of Gross Domestic Product (GDP)


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million, adding to a total of about 1.5% of National Health Service expenditure in that year.The most significant cost drivers are hypertension, coronary heart disease, and Type 2diabetes, followed by osteoarthritis and stroke (ibid). The probability that these figuresunderestimate the direct costs was acknowledged by the NAO, since it excludes potentiallyhigh costs such as care for obesity-related stroke patients (ibid). A review made by the UKPorGrow analysts (Millstone & Lobstein, 2006) also points out that these estimates are lowcompared to the findings of studies undertaken in other countries where, as shown in Table2.3, the direct costs of obesity have been estimated to lie between 2% and 8.5% of nationalhealth care budgets. [If this range applied in Greece, the direct costs of treatment for obesityand its consequences would be between 150 - 853 million euros at 2000 figures

*]

Table 2.3 Estimates of the direct costs of obesity to National Health Services.

Prevalence of obesity

(BMI>30)Country

Year of

estimate

Proportion of total

healthcare expenditure

due to obesity At time of

estimate

Latest

available

USA 1999 8.5% 30.5% 30.5%

USA 2000 4.8% 30.5% 30.5%

Netherlands 1981-89 4.0% 5.0% 10.3%

Canada 1997 2.4% 14.0% 13.9%

Portugal 1996 3.5% 11.5% 14.0%

Australia 1989/90 >2.0% 10.8% 22.0%

England 1998 1.5% 19.0% 23.5%

France 1992 1.5% 6.5% 9.0%

Source: House of Commons 2004 as cited by Millstone & Lobstein (2006)

Given that there is a time lag of several years between the onset of obesity and related healthproblems, rising health care costs are to be expected, particularly in view of the risingprevalence of childhood obesity. An indication of trends is provided by a US study ofobesity-associated hospital costs for children and adolescents (6-17y), which showed athree-fold increase over a twenty-year period (1979 1999) (Wang & Dietz, 2002).

Evaluation of the indirect costs associated with obesity rely on calculations of lost earningsand/or lost production arising from (a) the premature death of active members of theworkforce and (b) from days of medically certified sickness absence attributable to obesityand its consequences. There are currently no such estimates available in Greece. The NAO(2001) evaluation for England for 1998 indicates that these indirect costs might beenormous: an estimation of lost earnings of 2,149 million, of which 61% was due tosickness absence attributable to obesity, and the remainder to premature mortality.Moreover, the NAO analysts considered the amount of sickness absence attributed to obesity

*Calculations based on Eurostat (2002) compilations of total health expenditures for 2000 of 10 032 million

(8.3% of GDP). Calculations derived from more recent OECD (2005) figures for GDP for 2003 of $225,8 billionUSD, and total health expenditure as 9.9% of GDP, give a higher range: 300 million - 1.9 billion USD at 2003rates.


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(over 18 million days medically certified absence) to be an underestimate, as it excludes bothself-certified and uncertified sickness absence, and takes no account of sickness due todiseases for which the proportion of cases attributable to obesity cannot be quantified, e.g.

back pain (NAO, 2001)

There are other financial and intangible costs of obesity that are unaccounted for, includingthe social and psychological effects associated with being obese. For example, excess

bodyweight is linked to less chance of finding a marriage partner or a job, and of beingpromoted, particularly for women (Viner & Cole, 2005). Overweight people are likely to beon lower earnings (perhaps reducing the lost-days-of-work costs) but are more likely tosuffer low self-esteem and depression. Psychiatric problems, especially depression, are thelargest single cause of disability-adjusted-life-years (DALYs) in developed economies

7and

are also a major cost to the health services and a cause of lost productivity (Millstone &Lobstein, 2006).

Obesity and its co-morbidities are associated with substantial human costs in the form ofchronic disabilities, illnesses, and premature mortality. It also has serious financial costs fornational health services and for the economy. Data limitations mean that estimation of the

burden of disease and the accompanying economic costs attributable to obesity in Greece arematters of conjecture. Concern is, however, warranted by the relative deterioration in lifeexpectancy and by trends in the major diseases associated with obesity notablycardiovascular diseases and diabetes. (In particular, trends in CVD mortality rates do notmatch the decreasing trends observed in other Western European countries.) Thesedevelopments in the health profile of the population have been accompanied by an escalating

burden of clinical care.

Evidence suggests that many of the risks and complications of obesity are reversible or canbe mitigated by even modest weight losses (Astrup, 2001). While the success rate in treatingobesity is relatively low (IOTF 2005), there is evidence that adverse consequences /co-morbidities are increasingly being controlled or alleviated through medication andimprovements in health care. In view of the rising prevalence of obesity in Greece, there is a

pressing need to assess current and projected demands on the health services and respondaccordingly. Apart from collateral strategies for those affected, however, the principalchallenge lies in halting the upward trend, particularly among children.

Summary of main points in section 2

The various cost dimensions of obesity indicate a strong economic rationale for public

policy action. The population health profile of relative longevity and low rates of non-communicable

diseases has co-existed paradoxically with the rising prevalence of obesity.

Recent trends in morbidity and mortality data, particularly for cardiovascular diseasesand type 2 diabetes, indicates that this pattern no longer holds.

Rising morbidity rates have been accompanied by escalating health care costs.

Reliable estimates of the current and projected economic and health costs of obesity inGreece are needed to inform policy actions.

7 The WHO estimates that in Greece neuropsychiatric conditions are the second leading cause of DALYs for men(19.5% of total DALYs compared with 24.9% attributed to CVDs) and on a par with DALYs attributed to CVDsfor women (24.8%) (WHO 2003).


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It is generally accepted that weight gain is regulated by gene-environment interactions. Thatis, obesity develops on the background of a genetic predisposition, and increasedsusceptibility may occur through interaction with other factors, e.g. fetal programming(WHO,2000; Astrup 2001).The expression of genetic susceptibility, however, depends onenvironmental factors. Reviews of determinants indicate a high level of evidence andconsensus in this respect for the role of behavioural factors, such as low levels of physicalactivity and high intakes of energy-dense foods, and also some food composition factors,

such as high fat content, low fibre content. There is less robust evidence but significantinterest in potential determinants (eg breastfeeding, the glyceamic index of foods) and areasonable consensus that certain elements of the environment are important (eg the builtenvironment, advertising of food to young children, parental and family factors, and theschool environment). (WHO 2003; Swinburn et al 2004).

Reduced to its most basic equation, excessive weight gain develops in susceptible individualswhen energy intake exceeds energy expenditure or, as one analyst aptly put it, when they areexposed to an abundant availability of energy-dense, high fat, palatable foods and a lifestylecharacterized by physical inactivity (Astrup, 2001). Although many weight-control measuresare targeted at individuals, a simplistic approach which focuses exclusively on thebehavioural choices of individuals is fraught with moral connotations (gluttony-sloth) and the

accompanying risk of stigmatization. More fundamentally, it impedes our understanding ofhow the rising prevalence of obesity has occurred in our society. The public healthperspective as voiced by the WHO and IOTF looks to causal pathways: profound economicand social developments affecting behavioural patterns of communities over recent decades.A causal web framework developed by an IOTF working group illustrates the societalinfluences on obesity prevalence (Appendix Figure A3.1). It points to the complex linksbetween economic growth, technological developments, urbanization and globalization offood markets which are driving changes at regional and local level in areas such asagriculture, health and welfare, education, trade and commerce and thereby affecting foodavailability, eating habits and habitual physical activity. These processes are complex,dynamic and ongoing (Swinburn et al, 2005). There are, in short, a large number ofinfluences upstream affecting an individuals food choices and energy expenditure which,

as the WHO points out, calls for a balance between individual and population-wideapproaches, and between education-based and multi-sectoral environmental interventions(WHO 2003).

An assessment of policy options for effective interventions requires an understanding ofchanges in food consumption and physical activity patterns which have fueled the risingprevalence of obesity. This section looks at available data on the trends in Greece.


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The primary sources of data on food consumption are (a) Food Balance Sheets produced by

the Food & Agricultural Organization (FAOSTAT), (b) Household Budgetary Surveys, and(c) individual dietary surveys. FAOSTAT Food Balance Sheets (FBS) are based onagricultural production and trade statistics together with national accounts of food use. Thedata is supplied in total quantities and food for consumption is calculated per person of thepopulation. Household budgetary surveys (HBS) such as those conducted under the DataFood Networking Project (DAFNE), record data on the values and quantities of householdfood purchases, and can thereby indicate prevailing dietary patterns. FBS and HBS providedata on food availability, which is not synonymous with consumption. The latter is assessedby individual dietary surveys (IDS) which evaluate individual food and nutrient intake andprovide the best estimation of nutritional status.

These sources are not directly comparable as each provides data at a different stage in the

food delivery chain and each has its own advantages and limitations. FBS, for example, has arecognized tendency to overestimate food supplies in developed countries whereas HBSusually exclude foods eaten outside the home and thereby have a tendency to underestimateconsumption. A major weakness of IDS is the tendency for under-reporting. These issues andthe associated implications for developing guidelines and food policies have been reviewedrecently (Serra-Majem, 2001).

In terms of food availability, results from the DAFNE HBS in the early 1990s in 10 Europeancountries revealed considerable variations but identified a broad North/South classificationbased primarily on fruit and vegetable consumption and the type of added fats (lipids) used.Greece and the other southern countries were thus characterized by high intakes of fruit andvegetables (400g/person/day), almost all of which was fresh rather than processed, and high

added fat intake consisting almost totally of olive oil rather than animal fats (butter). Thisdietary pattern was linked with the pattern of diet-related diseases: a consistent North/Southgradient in mortality rates for ischaemic heart disease (IHD) and most cancers, with the Northhaving the higher rates. The shifting dietary patterns among Mediterranean populations wasalready apparent in the early 1990s, particularly in relation to increasing meat intakes.Moreover, as indicated in the previous section, we have been witnessing a convergence oftrends in IHD which have gone hand-in-hand with the rising prevalence of obesity throughoutEurope. DAFNE data provides a detailed snapshot of food availability at household level, butin looking at trends which might shed light on these developments the best available sourcefor Greece is the authoritative FAOSTAT data on food supplies and the availability ofspecific nutrients, supplemented by data on self-reported intake from dietary surveys.

Figure 3.1 illustrates the trend of a steadily increasing supply of food energy, expressed askilocalories (kcal). Since the 1970s, in common with most other European countries, theaverage food energy available per person in Greece has exceeded dietary recommendations8

8 Recommended Dietary Alowances (RDA) for most countries is about 2900 kcal for adult men and 2200 kcal forwomen in the age range 25-50y. Energy and nutrient needs vary considerably according to age and activity levels,with peak needs identified during the adolescent rapid growth phases. International and selected nationalrecommendations on nutrient intake values are collated by the WHO(2004). Guidelines proposed for European

populations are provided by Eurodiet (2001).


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and from the mid-1980s onwards it has been consistently higher than the EU-15 mean (but ona par with food energy availability in some other Mediterranean countries Italy andPortugal - and also in Ireland). In all European countries more food energy is supplied from

vegetable/plant products than animal products (Eurostat 2004). This is particularlypronounced in Greece, where plant sources continue to supply the great bulk of food energy.There has, however, been a steady increase in the importance of animal products (from 13%of total food energy in the early 1960s to 23% in 2003).

Figure 3.1. Supply of food energy: average number of calories (kcal) available per

person per day.



The FAO figures indicate an increase in food energy supply of about 450 kcal/person/daysince the 1970s9. As the UK PorGrow analysts have pointed out, for an average adult anincrease in food intake of 100kcal per day would lead to a gain in body weight of 3-4kg overa year, assuming no increase in energy expenditure. For the average man this represents aboutone BMI unit, and for a woman about 1.3 BMI units. Thus a 100kcal increase in net energyintake would result in a healthy weight adult becoming an obese adult in 7-10 years. Snack

foods containing 100kcal are easily found: a 330ml can of soft drink typically contains120kcal, a 30g bag of potato snacks 150kcal, and a 50g portion of chocolate 250kcal(Millstone & Lobstein, 2006).

Apart from a secure and increasingly abundant food supply, time trends in the supply ofcereals, fruit and vegetables, meat and milk illustrated in Figure 3.2 indicate the ways inwhich eating patterns in Greece have been changing. The characteristic of high levels ofcereals, vegetables and fruits persists, but whereas cereal availability has been generally staticsince the mid-1960s, vegetable and fruit supplies have been increasing. Interestingly, given

9 Mean for 1970-74 of 3237kcal compared with mean for 1999-2003 of 3695 kcal. (Derived from FAOSTAT 2006data).


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the documented preferences for consumers to increase their fruit rather than vegetable intake,the bulk of this increase has been provided by vegetables, with supplies nearly doubling sincethe mid-1960s (from about 165kg/person/yr in 1966 to 276kg/p/y in 2003, with a peak of

~300kg/p/y in the early 1990s) whereas apart from an apparent dip in the 1970s, supplies offruits have been relatively constant (fluctuating around 140kg/p/y). The WHO HFA databaseindicates that combined per capita supplies of fruits and vegetables have consistently beenamong the highest/ the highest in Europe. The persistence of this distinctive trait ofMediterranean diets has not been matched by trends in other food groups. Thus, milk supplieshave doubled since the 1960s to 262 kg/person/year in 2003, and the upward trajectorycontinues. But the most dramatic shift has been the three-fold increase in the availability ofmeats over this period (to ~80 kg/person/year in 2003) ;an upward trend which shows signsof converging with the EU-15 mean (91.5kg/p/y in 2003)

Figure 3.2. Time trends in the supply of (a) cereals, fruits and vegetables (b) meat and

milk (kg/person/year).

0

50

100

150

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250

300

350

400

450

500

1961 1966 1971 1976 1981 1986 1991 1996 2001 2003

Cereals

F&VegCombined

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300

1961 1966 1971 1976 1981 1986 1991 1996 2001 2003

Meat

Milk (exl butter)

Source: FAOSTAT (FBS) 2006.

The dramatic increase in meat and milk availability has contributed to the absolute increase inprotein available (from ~84g/person/dayin 1961 to 117 in 2003), although protein as apercentage of total food energy available has remained relatively constant over this period,fluctuating at/around 12%. Increasing supplies of meat and milk have, however, contributedto both the absolute and relative increase in fat. The absolute increase has been from about90-100 g/person/day in the late 1960s to ~145g/person/day since 2000; and fat as a


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percentage of total energy has increased from around 30% to 37% over the same period. Fat,which has nearly twice the calorie content per gram of sugar or protein, may thus be the mostsalient nutrient in explaining the rising food energy supply.

The gradual increase in the proportion of energy obtained from fat is common to mostEuropean countries and in all cases exceeds the FAO-WHO recommendations of no morethan 30% energy from fat(Eurostat, 2004). Greece retains the distinctive feature, shared withItaly and Spain, whereby more fat is supplied from plant sources than from animal sources.Reflecting increasing meat and milk supplies the balance has, however, been shifting. In the1960s and early 1970s between 65-70% of fat supplies came from vegetable sources whereasduring 2000-03 vegetable fats constituted 58-60% of the total available10. The continuingdominance of vegetable fats owes much to the reliance on olive oil although, as illustrated inFigure 3.3, the use of added fats/lipids has also been changing with increasing use made ofother vegetable oils from the mid-1980s onwards.

Figure 3.3 Time trends in supplies of olive oil, other vegetable oils and (added) animalfats, 1961-2003 (g/person/day).

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40

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70

80

90

1961-65 1966-70 1971-75 1976-80 1981-85 1986-90 1991-95 1996-00 2001-03

Animal fats

Other vegetable oils

Olive oil

Source: FAOSTAT (FBS) 2006

FAO data for sugars and sweeteners also shows a rapid increase in availability: from about15kg/person/year in the early 1960s to 31kg/p/y by the mid-1970s. Thereafter supplies havebeen relatively steady at around 31-35kg/person/year (compared with an EU-15 mean in 2003of 40.8kg/p/y). It should be noted that FAO data does not capture the increasing use beingmade of fructose and other sweeteners in processed foods and soft drinks which have beenimplicated in the rising prevalence of obesity11.

10 i.e. 60-70g/p/day from vegetable products vs 26-38 g/person/day fats from animal sources in the 1960s andearly 1970s compared with about 88g/p/day from vegetable sources and 56-60g/p/day from animal products

between 2000-03

11 Apart from the effects of fructose in disrupting energy homeostasis and lipid/carbohydrate metabolism (i.e. thebodys weight regulation mechanisms) (Havel, 2005), the increasing consumption of soft drinks sweetened withhigh-fructose corn syrup has also been associated with fueling the obesity epidemic in the United States through

partially displacing milk consumption and calcium intake, which is thought to be inversely associated with BMI.


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Moderate consumption of wine on a daily basis is another characteristic of the Mediterraneandiet. The homogenization of drinking patterns and diversification of alcoholic beverages

consumed has been observed throughout Europe, coupled with a tendency towardsconverging alcohol consumption levels (van der Wilk & Jansen, 2005). A reduction in wineconsumption and increasing beer consumption has been common to Southern wine-producingcountries. FBS data show this shifting pattern for Greece: within a general trend of increasingabsolute amounts of alcoholic beverages available (from ~40kg/person/year in the late 1960sto around 65kg/p/y in 2000-03.) wine constituted 80% of the total in the late 1960s, wasdisplaced by beer in the late 1970s/early1980s, and since then has been relatively stable atabout a third of the total alcoholic beverages available12. The extent to which this reflects therise in mass tourism as opposed to shifting consumption patterns of the indigenous populationis not known.

Determining how much of the food available is actually consumed is problematic,particularly when as in Greece there are no nationally representative food consumptionsurveys. Moreover, the comparability of existing regional surveys is complicated bydifferences in methods used, in population samples, and also by the continuing lack of anational food composition database. These issues and their implications are addressed indetail in a recent systematic review of the literature on food consumption in Greece (Ferro-Luzzi et al, 2002). These analysts focused on the changing fat intake and fat composition ofthe habitual diet. Evaluating available survey data from the Seven Countries Study onwards,they concluded that actual energy intake from fat has increased from about 30% in the 1960sto current levels estimated at 40-45%. Some variation by age and gender have been noted,

with intakes as high as 38-51% of energy being recorded for middle-aged and elderly womenof the Greek EPIC cohort (Trichopoulou & Lagiou, 1997). In part this is attributed to theincreasing availability of olive oil and in part to the introduction into the diet of other fatsources. This has been accompanied by an increase in dietary saturated fatty acids (SFA),which appear to have almost tripled over 30 years (to 11-14% energy) ie well above theWHO/FAO nutrient goals of


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Advocacy of a high-fat diet is contrary to international dietary recommendations. Thispolemic is, in short, at the crux of the relationship between diet, obesity and health and the

source of mixed messages to the Greek public as well as policy-makers about the benefits orotherwise of high-fat/lipid diets. As such the quality-quantity-health issues involved warrantsome unpacking/examination.

(a) Quality and quantity

A Spanish study has reported adherence to the traditional Mediterranean diet as beinginversely associated with BMI and obesity (Schroder et al, 2004). This effect was not,however, supported by analyses of the Greek EPIC cohort, which took into account thehigher lipid intakes of those closely adhering to the traditional diet 13. Specifically, the Greekstudy showed that adherence to the Mediterranean diet was unrelated to BMI but positively(albeit marginally) related to WHR among women (Trichopoulou et al, 2005). These resultsare held to be in line with the conclusions of a review of food intake patterns and BMI in

observational studies which indicated that no consistent associations have been identifiedbetween various dietary patterns and either BMI or obesity (Togo et al, 2001). The logic,then, is that assuming sufficient adjustment of portion sizes and/or physical activity toaccommodate the higher energy density of fats/lipids compared with other nutrients, neither ahigh-fat/lipid diet nor an increase in fat/lipid intakes will necessarily lead to overweight14. Butas the phenomenally high rates of obesity reported for the Greek EPIC cohort indicate, this issomething of a heroic assumption.

The extensive research on relationships between dietary fats, the energy-density of foods andweight gain has been recently reviewed (Swinburn et al, 2004). In brief: at a macronutrientlevel there is no evidence that energy from fat is more fattening than the same amount ofenergy from protein or carbohydrate The conclusion of fixed energy studies is that if a high

percentage fat diet promotes weight gain, the mechanism appears to be mediated bypromoting a higher total energy intake.Ad libitum trials (which do not restrict total intakes)demonstrate that, other things being equal, the physiological and behavioural consequences ofa high-fat diet is a slow weight gain through the passive overconsumption of total energy.Potential mechanisms for this passive overconsumption are effects of fats c

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