International Textbook of Obesity Edited by Per Bjo¨ rntorp Sahlgrenska Hospital, Go¨ teborg, Sweden JOHN WILEY & SONS, LTD Chichester ( New York ( Weinheim ( Brisbane ( Singapore ( Toronto International Textbook of Obesity. Edited by Per Bjorntorp. Copyright © 2001 John Wiley & Sons Ltd Print ISBNs: 0-471-988707 (Hardback); 0-470-846739 (Electronic) huangzhiman 2002.12.19 Copyright © 2001 by John Wiley & Sons, Ltd., Baffins Lane, Chichester, West Sussex PO19 1UD, UK National 01243 779777 International ( ; 44) 1243 779777 e-mail (for orders and customer service enquiries): cs-books@wiley.co.uk Visit our Home Page on: http://www.wiley.co.uk or http://www.wiley.com All Rights Reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, scanning or otherwise, except under the terms of the Copyright, Designs and Patents Act 1988 or under the terms of a licence issued by the Copyright Licensing Agency Ltd, 90 Tottenham Court Road, London W1P 0LP, UK, without the permission in writing of the publisher. Cover illustration copyright © Sofia Karlsson and Lars Sjo¨ stro¨m. Reproduced by permission. Other Wiley Editorial Offices John Wiley & Sons, Inc., 605 Third Avenue, New York, NY 10158-0012, USA WILEY-VCH Verlag GmbH, Pappelallee 3, D-69469 Weinheim, Germany John Wiley & Sons Australia, Ltd., 33 Park Road, Milton, Queensland 4064, Australia John Wiley & Sons (Asia) Pte, Ltd., 2 Clementi Loop 02-01, Jin Xing Distripark, Singapore 129809 John Wiley & Sons (Canada), Ltd., 22 Worcester Road, Rexdale, Ontario M9W 1L1, Canada Library of Congress Cataloging-in-Publication Data International textbook of obesity / edited by Per Bjo¨ rntorp, p. cm. Includes bibliographical references and index. ISBN 0-471-98870-7 (cased) 1. Obesity. I. Bjo¨ rntorp, Per. RC628.I58 2001 616.398—dc21 00-048591 British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library ISBN 0-471-98870-7 Typeset in 10/11.5pt Times from the author’s disks by Vision Typesetting, Manchester Printed and bound in Great Britain by Bookcraft (Bath) Ltd, Midsomer Norton, Somerset This book is printed on acid-free paper responsibly manufactured from sustainable forestry, in which at least two trees are planted for each one used for paper production. MMMM International Textbook of Obesity. Edited by Per Bjorntorp. Copyright © 2001 John Wiley & Sons Ltd Print ISBNs: 0-471-988707 (Hardback); 0-470-846739 (Electronic) 17. Obesity and Hormonal Abnormalities 225 Renato Pasquali and Valentina Vicennati 18. Cortisol Metabolism 241 Brian R. Walker and Jonathan R. Seckl 19. Drug-induced Obesity 269 Leif Breum and Madelyn H. Fernstrom 20. Pregnancy 283 Helen E. Harris 21. Social and Cultural Influences on Obesity 305 Jeffery Sobal 22. Cessation of Smoking and Body Weight 323 Kenneth D. Ward, Robert C. Klesges and Mark W. Vander Weg P VC 337 23. Visceral Obesity and the Metabolic Syndrome 339 Roland Rosmond 24. Obesity and Type 2 Diabetes Mellitus 351 Allison M. Hodge, Maximilian P. de Courten and Paul Zimmet 25. Cardiovascular Disease 365 Antonio Tiengo and Angelo Avogaro 26. Obesity, Overweight and Human Cancer 379 Michael Hill 27. Pulmonary Diseases (Including Sleep Apnoea and Pickwickian Syndrome) 385 Tracey D. Robinson and Ronald R. Grunstein 28. Obesity and Gallstones 399 S. Heshka and S. Heymsfield P VI M 411 29. Health Benefits and Risks of Weight Loss 413 Lalita Khaodhiar and George L. Blackburn 30. Treatment: Diet 441 Stephan Ro¨ ssner 31. Recent and Future Drugs for the Treatment of Obesity 451 Luc F. van Gaal, Ilse L. Mertens and Ivo H. De Leeuw 32. Treatment: Hormones 471 Bjo¨ rn Andersson, Gudmundur Johannsson and Bengt-A ke Bengtsson 33. Why Quality of Life Measures Should Be Used in the Treatment of Patients with Obesity 485 Marianne Sullivan, Jan Karlsson, Lars Sjo¨ stro¨ m and Charles Taft 34. Surgical Treatment of Obesity 511 John G. Kral 35. Swedish Obese Subjects, SOS 519 Lars Sjo¨ stro¨m Index 535 vi CONTENTS loss Contributors David B. Allison Obesity Research Center, St Lukes/Roosevelt Hospital Center, 1090 Amsterdam Avenue, 14th Floor, New York, NY 10025, USA Email: dba8@columbia.edu Bjo¨ rn Andersson Department of Medicine, Sahlgrenska University Hospital, University of Go¨teborg, S-413 45 Go¨teborg, Sweden Email: bjorn.andersson@medfak.gu.se Vicki J. Antipatis MSc International Obesity Task Force, Rowett Research Institute, Greenburn Road, Bucksburn, Aberdeen AB21 9SB, UK Email: Vantipatis@aol.com Angelo Avogaro Department of Clinical and Experimental Medicine, University of Padova, Via Giustiniani 2, 35100 Padova, Italy Bengt-A ke Bengtsson Research Center for Endocrinology and Metabolism, Sahlgrenska University Hospital, University of Go¨teborg, S-413 45 Go¨teborg, Sweden Per Bjo¨ rntorp MD PhD Professor, Department of Heart and Lung Diseases, Sahlgrenska University Hospital, University of Go¨teborg, S-413 45 Go¨teborg, Sweden Email: Per.Bjorntorp@hjl.gu.se George L. Blackburn MD PhD Professor and Director of Nutritional Services, Department of Surgery, Beth Israel Deaconess Hospital, 330 Brookline Avenue, Boston MA 02215, USA Email: gblackbu@bidmc.harvard.edu John E. Blundell BioPsychology Group, University of Leeds, Leeds LS2 9JT, UK Email: J.E.Blundell@leeds.ac.uk Leif Breum MD Department of Medicine, Endocrine Unit, Køge Hospital, DK-4600 Køge, Denmark Email: leif.breum@dadlnet.dk Maximilian P. de Courten MD MPH International Diabetes Institute, 260 Kooyong Road, Caulfield Vic 3162, Australia Ivo H. De Leeuw Department of Endocrinology, Metabolism and Clinical Nutrition, University Hospital Antwerp, Wilrijkstraat 10, 2650 Edegem, Antwerp, Belgium Jean-Pierre Despre´ s Division of Kinesiology and Department of Food Sciences and Nutrition, Laval University, Ste-Foy, Quebec, Canada G1K 7P4 Bjo¨ rn Ekblom Department of Physiology and Pharmacology, Lidingo¨va¨gen 2, Karolinska Institute, 11486 Stockholm, Sweden Madelyn H. Fernstrom PhD Professor, Weight Management Center, University of Pittsburgh School of Medicine, Western Psychiatric Institute and Clinic, 3811 O’Hara Street, Pittsburgh PA 15213, USA Email: fernstrommh@msx.upmc.edu Kevin R. Fontaine Department of Medicine, Division of Gerontology, University of Maryland, VA Medical Center, Baltimore, Maryland, USA Tim P. Gill PhD RPHNutr International Obesity TaskForce, Rowett Research Institute, Greenburn Road, Bucksburn, Aberdeen AB21 9SB, UK Email: tim.gill@iotf.org Ronald R. Grunstein FRACP PhD MD Centre for Respiratory Failure and Sleep Disorders, Level 9, E Block, Royal Prince Alfred Hospital, Camperdown, Sydney NSW 2050, Australia Email: rrg@mail.med.usyd.edu.au International Textbook of Obesity. Edited by Per Bjorntorp. Copyright © 2001 John Wiley & Sons Ltd Print ISBNs: 0-471-988707 (Hardback); 0-470-846739 (Electronic) T.S. Han PhD Wolfson College, University of Cambridge, Cambridge CB3 9BB, UK Email: tsh24@cam.ac.uk Barbara C. Hansen PhD Professor and Director, Obesity and Diabetes Research Center, University of Maryland School of Medicine, 10 South Pine Street 6-00, Baltimore, Maryland 21201, USA Email: bchansen@aol.com Helen H. Harris PHLS Communicable Disease Surveillance Centre, 61 Collindale Avenue, London NW9 5EQ, UK Email: HHarris@phls.org.uk Berit Lilienthal Heitman Institute of Preventive Medicine, Copenhagen Health Services, Copenhagen Municipal Hospital, DK-1399 Copenhagen K, Denmark Email: Behe@glostruphosp.kbhamt.dk Moonseong Heo Obesity Research Center, St Luke’s/Roosevelt Center, 1090 Amsterdam Avenue, 14th Floor, New York, NY 10025, USA S. Heshka St Luke’s/Roosevelt Hospital Center, 1111 Amsterdam Avenue, New York, NY 10025, USA Steven B. Heymsfield PhD Weight Control Unit, Obesity Research Center, St Luke’s/Roosevelt Hospital Center, 1090 Amsterdam Avenue, 14th Floor, New York, NY 10025, USA Email: SBH2@Columbia.edu Michael Hill DSc FRCPath Chairman, European Cancer Prevention Organisation; Professor, Nutrition Research Centre, South Bank University, 103 Borough Road, London SE1 0AA, UK Allison M. Hodge BAgSc BSc GradDipDiet International Diabetes Institute, 260 Kooyong Road, Caulfield, Victoria 3162, Australia Email: ahodge@accv.org.au Daniel J. Hoffman PhD MPH Obesity Research Center, St Luke’s/Roosevelt Medical Center, 1090 Amsterdam Avenue, 14th Floor, New York, NY 10025, USA Email: djh100@columbia.edu Bernard Jeanrenaud Lilly Research Laboratories, Division of Endocrine Research and Clinical Investigation, Lilly Corporate Center, Indianapolis, Indiana 46285, USA Susan A. Jebb MRC Human Nutrition Research, Downhams Lane, Cambridge CB4 1XJ, UK Email: Susan.Jebb@mrc-hnr.cam.ac.uk Gudmundur Johannsson Research Center for Endocrinology and Metabolism, Sahlgrenska University Hospital, University of Go¨teborg, S-413 45 Go¨teborg, Sweden Jan Karlsson Health Care Research Unit, Sahlgrenska University Hospital, University of Go¨teborg, S-413 45 Go¨teborg, Sweden Lalita Khaodhiar MD Fellow in Clinical Nutrition, Beth Israel Deaconess Medical Center, 1 Autumn Street, Harvard Medical School, Boston, Massachusetts 02215, USA Robert C. Klesges PhD University of Memphis Center for Community Health, 5350 Poplar Avenue, Memphis, TN 38119, USA John G. Kral MD PhD SUNY Downstate Medical Center, 450 Clarkson Avenue, Box 40, Brooklyn, New York 11203, USA Email: jgkral@hscbklyn.edu M.E.J. Lean MA MD FRCP Department of Human Nutrition, University of Glasgow, Glasgow Royal Infirmary, Glasgow G31 2ER, UK Email: mej.lean@clinmed.gla.ac.uk Bernt Lindahl MD Behavioural Medicine, Department of Public Health and Clinical Medicine, Umea˚ University, SE-901 87 Umea˚, Sweden Email: bernt.lindahl@medicin.umu.se Lauren Lissner Department of Medicine, Sahlgrenska University Hospital, University of Go¨teborg, S-413 45 Go¨teborg, Sweden Ilse L. Mertens Department of Endocrinology, Metabolism and Clinical Nutrition, University Hospital Antwerp, Wilrijkstraat 10, 2650 Edegem, Antwerp, Belgium Renato Pasquali MD Endocrinology Unit, Department of Internal Medicine and Gastroenterology, S. Orsola-Malphighi Hospital, Via Massarenti 9, 40138 Bologna, Italy Email: rpasqual@almadns.unibo.it C.M. Pond Department of Biology, The Open University, Milton Keynes MK7 6AA, UK Email: C.M.Pond@open.ac.uk viii CONTRIBUTORS Andrew M. Prentice MRC Human Nutrition Research, Elsie Widdarson Laboratory, Fulbourn Road, Cambridge CB1 9NL, UK Email: Andrew.Prentice@lshtm.ac.uk Tracey D. Robinson MB BS FRACP Centre for Respiratory Failure and Sleep Disorders, Royal Prince Alfred Hospital, Camperdown, Sydney NSW 2050, Australia Email: traceyr@mail.med.usyd.edu.au Franc¸ oise Rohner-Jeanrenaud Laboratoires de Recherches Metaboliques, Geneva University School of Medicine, Geneva, Switzerland Email: Jeanrenaud—Francoise@Lilly.com Roland Rosmond Department of Heart and Lung Diseases, Sahlgrenska University Hospital, University of Go¨teborg, S-413 45 Go¨teborg, Sweden Stephan Ro¨ ssner Professor, Obesity Unit, M73, Huddinge University Hospital, S-141 86 Stockholm, Sweden Email: Stephan.Rossner@medhs.ki.se Jonathan R. Seckl University of Edinburgh, Endocrinology Unit, Department of Medical Sciences, Western General Hospital, Edinburgh EH4 2XU, UK Jacob C. Seidell PhD Department of Chronic Diseases Epidemiology, National Institute of Public Health and Environmental Protection, Institute for Research in Extramural Medicine, Free University Amsterdam, PO Box 1, 3720 BA Bilthoven, Amsterdam, The Netherlands Email: j.seidell@rivm.nl Carol A. Shively PhD Department of Pathology (Comparative Medicine), Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157-1040, USA Email: cschively@cpm.wfubmc.edu Lars Sjo¨ stro¨ m Department of Internal Medicine, Sahlgrenska University Hospital, University of Go¨teborg, S-413 45 Go¨teborg, Sweden Email: lars.sjostrom@medfak.gu.se Jeffery Sobal PhD MPH Division of Nutritional Sciences, Cornell University, 303 MVR Hall, Ithaca NY 14853, USA Email: js57@cornell.edu Marianne Sullivan Professor, Health Care Research Unit, Sahlgrenska University Hospital, University of Go¨teborg, SE-413 45 Go¨teborg, Sweden Email: healthcare.research@medicine.gu.se Charles Taft Health Care Research Unit, Sahlgrenska University Hospital, University of Go¨teborg, SE-413 45 Go¨teborg, Sweden Corrado Testolin Obesity Research Center, St Luke’s/Roosevelt Hospital Medical Center, 1090 Amsterdam Avenue, 14th Floor, New York, NY 10025, USA Antonio Tiengo Department of Clinical and Experimental Medicine, University of Padova, Via Giustiniani 2, 35100 Padova, Italy Email: tiengo@ux1.unipd.it Angelo Tremblay Division of Kinesiology and Department of Food Sciences and Nutrition, Physical Activity Sciences Laboratory, Laval University, Ste-Foy, Quebec, Canada G1K 7P4 Email: angelo.tremblay@kin.msp.ulaval.ca Luc F. van Gaal Professor, Department of Endocrinology, Metabolism and Clinical Nutrition, University Hospital Antwerp, Wilrijkstraat 10, 2650 Edegem, Antwerp, Belgium Mark W. Vander Weg PhD Professor, University of Memphis Center for Community Health, 5350 Poplar Avenue, Memphis, TN 38119, USA Valentina Vicennati Endocrinology Unit, Department of Internal Medicine and Gastroenterology, S. Orsola-Malpighi Hospital, Via Massarenti 9, 40138 Bologna, Italy Brian R. Walker University of Edinburgh, Endocrinology Unit, Department of Medical Sciences, Western General Hospital, Edinburgh EH4 2XU, UK Email: B.Walker@ed.ac.uk Jeanne M. Wallace Department of Pathology (Comparative Medicine), Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157-1040, USA ZiMian Wang Obesity Research Center, St Luke’s/Roosevelt Hospital Center, 1090 Amsterdam Avenue, 14th Floor, New York, NY 10025, USA ixCONTRIBUTORS Kenneth D. Ward PhD Assistant Professor, University of Memphis Center for Community Health, 5350 Poplar Avenue, Suite 675, Memphis, TN 38119, USA Email: kdward@memphis.edu Paul Zimmet MD PhD FRACP Professor, International Diabetes Institute, 260 Kooyong Road, Caulfield, Victoria 3162, Australia Email: pzimmet@netscace.net.au x CONTRIBUTORS Preface Why another book on obesity? Recently we have seen several similar books of which some are very comprehensive. The finalizing of this book has been delayed. It was originally meant to be presented at the Paris Congress as another armament in the current worldwide fight against obesity. This first planned book was rather limited in contents, but it was eventually decided to cover additional fields, and here is the result. The field of modern obesity research is fairly young and has expanded considerably with time. The ‘pioneers’ who began this research are still to a large extent active, and several have contributed to this book with reviews in their respective sub- speciality of obesity research. One ambition with the present book was to invite several younger re- searchers to write chapters. In this way new angles of the problem have been presented. Rethinking and research should go hand in hand. Although things appear to improve, I have the impression that at least in certain countries obesity is still not considered with sufficient seriousness. The economic arguments seem to have made some politicians and decision makers raise their eye- brows. The involvement of central, international organizations in making recommendations should have an effect. National problems of obesity are now also the subject of surveys in several countries and counteractions are planned. A major problem is, however, that we still have difficulties impressing ourselves on adjacent areas of research. To take one example, during a recent major congress on diabetes mellitus I asked a hand- ful of leading diabetes researchers the following questions: Which is the major problem in diabetes research? Unanimous answer: diabetes mellitus type 2. Which is the most frequent risk factor or precursor state to this type of diabetes? Unanimous answer: obesity. I then suggested that we should join forces and see what can be done to prevent and treat obesity more successfully than is possible to- day. This was met with considerable enthusiasm. The obesity and diabetes fields are largely over- lapping. As a matter of fact obesity might be con- sidered as the first step towards diabetes, where beta-cell insufficiency is eventually added. I think it would be extremely useful for both fields to collab- orate more than is now the case. In a way the current situation is reminiscent of the clinical sub- specialization where various organs are treated by different specialists, who have difficulties in seeing the world outside the fence, and thereby miss im- portant information that might benefit the patient. What we could do, as an initial step, is to reserve large parts of obesity meetings for diabetes and vice versa. Several presidents for upcoming congresses in both obesity and diabetes have, as a response to a direct question, agreed that this is a good idea, and we will see if this is only lip-service or if the idea has been taken seriously. The concept of the metabolic syndrome, a syn- drome strongly associated with abdominal obesity, has been very helpful in facilitating the realization that we are to a large extent dealing with a common background to prevalent diseases. The awareness of this syndrome has had the consequence that the complex obesity—insulin resistance—dyslipidaemia— hypertension is often discussed as a cluster in con- gresses of diabetes, cardiology and hypertension. The realization of this clustering of symptoms has also had an impact on clinical activities, and has led to work-up outside one particular specialty. It is now more frequent that hypertensiologists deter- mine circulating lipids and that cardiologists exam- ine insulin resistance, and, most importantly, register height, weight and body circumferences. International Textbook of Obesity. Edited by Per Bjorntorp. Copyright © 2001 John Wiley & Sons Ltd Print ISBNs: 0-471-988707 (Hardback); 0-470-846739 (Electronic) This is clearly a large step forward. Writing chapters for a book like this is a major task, interfering with the activities of an already busy day. I would like to thank the contributors who have taken on the task of writing chapters for this book, and also Wiley who asked me to organize it. The collaboration with Michael Osuch and Han- nah Bradley has been very pleasant. Per Bjo¨ rntorp University of Go¨ teborg, Sweden x PREFACE Part I Epidemiology MMMM [...]... (Glasgow) 9 11 17 18 19 9 13 18 20 11 15 10 11 11 11 10 13 22 24 22 13 17 18 24 14 17 16 14 13 23 11 10 23 20 17 11 17 15 22 15 18 23 14 14 16 11 12 24 25 19 10 22 21 23 18 19 25 14 16 23 Mean 13 .5 17 .3 16 .4 18 .8 THE EPIDEMIOLOGY OF OBESITY 25 Table 2.4 Prevalence of obesity (age standardized % with BMI 930 kg/m) of centres in countries outside the European Union participating in the first round of the... (Novi Sad) 24 15 4 32 18 16 19 18 19 21 19 29 11 15 23 12 13 22 17 20 14 4 25 11 16 19 16 12 18 15 18 12 15 17 9 11 14 15 31 17 21 48 17 23 23 21 — 26 25 40 23 26 33 14 18 27 32 19 14 8 30 8 20 21 19 — 21 15 26 17 15 22 10 11 19 26 In general, the prevalence of a large waist is higher than the prevalence of obesity and this is because it also includes overweight subjects with abdominal obesity OBESITY IN... 19 91/ 93 19 95 19 97 19 95 19 94 19 97? 19 95 19 92 19 90 19 96 20—75 20—59 16 —64 16 —64 15 ; 15 ; 20—65 25—69 25—69 Adults 14 8.4 17 16 6.5 8.6 22.6 21 17 10 .8 11 8.3 20 17 6.3 8.4 25.6 27 19 27.9 North America Canada USA 19 91 1988—94 18 —74 20—74 15 19 .9 15 24.9 Central and South America Mexico (urban) Brazil Curacao ¸ 19 95 19 89 19 93/94 Adults 25—64 18 ; 11 5.9 19 23 13 .3 36 Middle East Iran, Islamic Republic of. .. 12 19 18 13 14 13 22 18 15 .6 17 16 13 22 15 8 15 22 17 16 .1 14 12 14 26 32 33 43 32 30 26.2 18 9 16 28 37 21 43 29 27 25.3 Outside Europe China (Beijing) USA (Stanford) 3 10 4 22 10 14 8 23 Figure 2 .1 Time-trends of the prevalence of obesity in adults in the Health Survey for England (ages 16 ;), 19 87 19 97 and in the Netherlands (MORGEN project, ages 20—65 years), 19 87 19 97 ized or even slightly decreased... Arabia 19 93/94 20—74 2.5 7.7 19 89/90 19 94 19 94—96 19 91/ 92 19 90/93 35—64 18 ; 25; 20—65 15 ; 19 32 32.7 9.5 16 24 44 59.8 30.3 24 18 .0 10 58.4 36.6 18 .0 13 76.8 54.3 Australasia and Oceania Australia (urban) New Zealand Samoa (urban) Papua New Guinea (urban) 19 95 19 89 19 91 19 91 25—64 18 —64 25—69 25—69 South and East Asia Japan India (urban Delhi middle class) China Malaysia Singapore@ Kyrgyzstan 19 93 19 97... the existing WHO standards, the 19 98 World Health Report indicated that about 22 mil- OBESITY AS A GLOBAL PROBLEM 19 Table 1. 9 Prevalence of overweight? in 6- to 8-year-old children USA (19 88 19 91) Girls Boys China (19 93) Russia (19 94 19 95) South Africa (19 94) Brazil (19 89) 24.2 21. 3 12 .2 14 .1 17.8 25.6 20.3 25.0 10 .5 12 .8 ?Defined as BMI higher than the US reference NHES 85th percentile Source: Popkin... Kyrgyzstan 19 93 19 97 20; 40—60 1. 7 3 .19 2.7 14 .28 19 92 19 92 19 93 20—45 18 —60 Adults 18 —59 1. 2 4.7 4 4.2 1. 64 7.9 6 10 .7 Mauritius Tanzania Rodrigues (Creoles) Cape Peninsula (Coloured) 19 92 19 86/89 19 92 19 90 25—74 35—64 25—69 15 —64 5.3 0.6 10 7.9 15 .2 3.6 31 44.4 Africa ?Data are from the Italian National Health Survey and are self-reported @Obesity criterion: BMI P 31 kg/m A similar picture is emerging... and by 7% in 7-year-old girls between 19 72 and 19 94 In Scotland over the same period, triceps skinfold measurement increased by nearly 10 % in 7-year-old boys and by 11 % in 7-year-old girls Weight for height index followed a similar pattern Childhood obesity is also increasing in Asia In Thailand, the prevalence of obesity in 6- to 12 -yearold children rose from 12 .2% in 19 91 to 15 .6% in 19 93 In Izumiohtsu... Epidemiol 19 96; 6: 266—275 14 Gopalan C Obesity in the Indian urban ‘Middle Class’ Nutrition Foundation of India Bulletin 19 98; 19 : 1 5 15 Seidell JC Obesity in Europe Obes Res 19 95; 3 (Suppl 2): 89s—93s 16 Hodge AM, Dowse GK, Toelupe P, Collins VR, Imo T, Zimmet PZ Dramatic increase in the prevalence of obesity in Western Samoa over the 13 -year period 19 78 19 91 Int J Obes 19 94; 18 : 419 —428 17 Flegal... training 6 INTERNATIONAL TEXTBOOK OF OBESITY Table 1. 4 Conservative estimates of the direct economic costs of obesity Country Year Obesity definition Estimated direct costs % National health care costs USA Australia Netherlands France 19 95 19 89/90 19 81 89 19 92 BMI P30 BMI 930 BMI 925 BMI P27 US$52 billion AUD$464 million Guilders 1 billion FF 12 billion 5.7 92 4 2 Table 1. 5 Estimated world prevalence of obesity . Women Europe Finland 19 91/ 93 20—75 14 11 Netherlands 19 95 20—59 8.4 8.3 UK England 19 97 16 —64 17 20 Scotland 19 95 16 —64 16 17 ?Italy 19 94 15 ; 6.5 6.3 France 19 97? 15 ; 8.6 8.4 Czech Republic 19 95 20—65. Germany 19 92 25—69 21 27 former West Germany 19 90 25—69 17 19 Russia 19 96 Adults 10 .8 27.9 North America Canada 19 91 18—74 15 15 USA 19 88—94 20—74 19 .9 24.9 Central and Mexico (urban) 19 95 Adults 11 . 59.8 Bahrain (urban) 19 91/ 92 20—65 9.5 30.3 Saudi Arabia 19 90/93 15 ; 16 24 Australasia Australia (urban) 19 95 25—64 18 .0 18 .0 and Oceania New Zealand 19 89 18 —64 10 13 Samoa (urban) 19 91 25—69 58.4 76.8 Papua