2015 Milan Declaration: A Call to Action on Obesity
A Statement of the members of the European Association for the Study of Obesity to EXPO 2015
EASO formally presented our Milan Declaration to the Milan EXPO in a special session on Saturday 6th June, organised as part of the official EXPO programme and hosted in the EU Commission Pavilion. The session featured presentations from EASO Executive Committee members and Patient Council representatives, and was supported by presentations from representatives of the European Commission, WHO, the Milan EXPO Scientific Committee, the University of Milan and the Italian Ministero delle Politiche Agricole, Alimentari e Forestali.
Although obesity was only introduced in the 1950s into the International Classification of Diseases (ICD-10 code E66, currently) it had already reached epidemic proportions by the end of the century becoming one of the leading causes of death and disability worldwide. According to the World Health Organization (WHO) the prevalence of obesity has tripled since the 1980s in many countries of the WHO European Region. In 2008, 1.5 billion adults, 20 and older, were overweight with an estimated 500 million adults worldwide being obese (over 200 million men and nearly 300 million women); approximately 65% of the world’s population inhabit countries where overweight and obesity kill more people than underweight. The figures of affected individuals rage on unabated and more than 40 million children under the age of five were overweight in 2010. It is important to note that severe obesity [i.e., a body mass index (BMI) >35 kg/m2] is a rapidly growing segment of the obesity epidemic in which the detrimental effects are particularly evident and harsh. Moreover, obesity not only disproportionately affects the disadvantaged segments of the population, but these groups experience the most important increases in obesity prevalence. As a harbinger of a multitude of disabling and fatal diseases, obesity represents one of the most challenging public health concerns of the 21st century, threatening to reverse many of the health gains across the lifecourse achieved thus far. Indeed, the WHO has declared obesity as the largest global chronic health problem in adults, which is emerging as a more serious world problem than malnutrition. Healthy nutrition should be recognised and be prioritised as a primary approach in the context of prevention and management of overweight and obesity.
A progressive disease, impacting severely on individuals and society alike, it is widely acknowledged that obesity is the gateway to many other disease areas, including most NCDs (Non Communicable Diseases). Obesity plays a central role in the development of a number of risk factors and chronic diseases like hypertension, dyslipidaemia and type 2 diabetes mellitus inducing cardiovascular morbidity and mortality. If obesity is prevented and appropriately managed, we can block a major supply route to ill health. Obesity should therefore be viewed as one of the primary targets for current efforts to combat the increasing NCDs epidemic. Obesity is a serious, chronic disease that will only worsen without thoughtful and evidence-based interventions, and as the obesity epidemic worsens, so too will the prevalence of NCDs.
To address this situation, obesity should become a top priority, with increased commitment for concerted, coordinated and specific actions. A comprehensive, sustainable and pro-active strategy to deal with the challenges posed by the obesity epidemic is urgently needed. Encouraging the development and implementation of programmes for prevention, early diagnosis and treatment is mandatory. It is clearly imperative that obesity, as a disease and as a gateway to NCDs, is targeted as an area for immediate action and priority for research, innovation and action. In 1999 EASO issued a Milan Declaration in which we called for recognition, support and national action in this field. In the intervening years great progress has been made – but more needs to be done and we must act now.
It is clear that weight management must now play a major role in reducing morbidity and mortality of populations in Europe and world-wide. EASO resolves to provide leadership, guidance and support to governments, as part of its mission of facilitating and engaging in actions that reduce the burden of unhealthy excess weight in Europe through prevention and management, but a wider effort is needed. EASO therefore calls on governments, health agencies and all relevant stakeholders to:
- Recognise that individuals and communities who are obese require understanding, respect and support.
- Recognise that overweight and obesity are major causes of ill health which present huge social and economic burdens to European states.
- Recognise that obesity, beyond being in some cases a highly disabling and fatal disease per se, represents a major contributor to NCDs.
- Recognise that by prioritising the prevention and management of obesity, health agencies can cost effectively reduce the burden of NCDs (particularly if management is commenced early in life)
- Adopt and promote a multi-stakeholder approach to identifying and implementing practical solutions for tackling obesity.
- Prioritise obesity as a national health action, by developing, supporting and implementing national strategies for action on obesity. These strategies must prioritise medical education (undergraduate and HCPs) and public information campaigns.
- Prioritise the identification of critical unmet needs in obesity research, clinical care, education and training and other areas that have yet to be adequately addressed.
- Support national and European research that will inform and develop new and effective prevention and management
EASO National Associations:
Austria – Austrian Obesity Association President Prof. Bernhard Ludvik
Belgium – Belgium Association for the Study of Obesity President Prof. Dr. Jean-Paul Thissen
Bulgaria – Bulgarian Association for Study of Obesity and Related Diseases President Prof. Svetoslav Handjiev
Croatia – Croatian Obesity Association President Prof. Davor Stimac
Czech Republic – Czech Society for the Study of Obesity President Prof. Martin Haluzik
Denmark – Dansk Selskab for Adipositasforskning President Prof. Jens Bruun
Finland – Finnish Association for the Study of Obesity President Dr. Kirsi Virtanen
France – Association Francaise d’Etudes et de Recherches sur l’Obesite President Prof. Olivier Ziegler
Georgia – Georgian Association for the Study of Obesity President Dr. Ketevan Asatiani
Germany – Deutsche Adipositas Gesellschaft President Prof. Dr. Martin Wabitsch
Greece – Hellenic Medical Association for Obesity President Dr. Efthymios Kapantais
Hungary – Hungarian Society for the Study of Obesity President Dr. Eszter Halmy
Iceland – Icelandic Association for the Study of Obesity President Dr. Erla Gerdur Sveinsdóttir
Ireland – Association for the Study of Obesity on the Island of Ireland (ASOI) President Dr. Grace O’Malley
Israel – Israeli Society for the Study and Prevention of Obesity President Prof. Yishai Levy
Italy – Societa Italiana dell’Obesita President Prof. Paolo Sbraccia
Macedonia – Macedonian Association for Obesity President Prof. Dr. Slavika Subeska
Montenegro – Montenegro Society for Obesity President Dr. Igor Bjeladinovic
Netherlands – Netherlands Association for the Study of Obesity President Dr. Gijs Goossens
Norway – Norwegian Association for the Study of Obesity President Prof. Gunnar Mellgren
Poland – Polish Association for the Study of Obesity President Associate Prof. Magdalena Olszanecka-Glinianowicz
Portugal – Sociedade Portuguesa para o Estudo da Obesidade President Prof. Davide Carvalho
Romania – Romanian Association for the Study of Obesity President Associate Prof. Gabriela Roman
Russia – Russian National Association of Dieticians and Nutritionists, Working Group for the Study of Obesity President Prof. Gennadii Ivanovich Storozhakov
Serbia – Serbian Association for the Study of Obesity President Prof. Dr. Dragan Micic
Slovakia – Slovak Obesitology Section of Slovak diabetology Society President Dr. Lubomira Fabryova
Slovenia – Professional Section of the Slovenian Association for Obesity President Prof. Tina Sentocnik
Spain – Sociedad Espanola para el Estudio de la Obesidad President Prof. Felipe Casanueva
Sweden – Swedish Association for the Study of Obesity President Prof. Car-Erik Flodmark
Switzerland – Swiss Assosciation for the Study of Metabolism and Obesity President Prof. Kurt Laederach
Turkey – Turkish Association for the Study of Obesity President Prof. Nazif Bagriacik
UK – Association for the Study of Obesity President Prof. Pinki Sahota
World Obesity Federation – President Prof. Walmir Coutinho (Brazil)
The International Federation for the Surgery of Obesity and Metabolic Disorders European Chapter – President Prof.Alberic Fiennes (UK)
EASO Executive Committee
EASO Network of Collaborating Centres for Obesity Management (COMs)
Weight management seen from a social perspective
Stigmatisation of obese persons increases daily. Research shows that stigma leads to shame, which in turn leads to stress and therein a number of risk factors and chronic diseases – the very diseases often related to obesity. If only the physical body required attention, one might succeed in achieving at least temporary weight-loss through dieting. Dieting involves starving the body, restricting both the amount and the quality of food, which is a contradictory, since food can be the biggest single contributor to health!
But obesity involves more than the body! It is a person who is asking for help. It might not be weight loss that the person is asking for, but in any case, the patient always needs to be shown recognition and treated with respect. The medical profession has knowledge of disease and treatment, while the patient has the experience of living with the disease. A meaningful approach to the treatment of obesity would involve establishing a collaboration based on trust between caregiver and patient.
The common belief “just lose weight and you will be happy” has no basis in reality. For many of us who have had a long – term experience of obesity, often since childhood, it is not only weight that changes; there is also an impact on your personal identity. Nothing fits – clothes, shoes, even your social life can be affected. You have changed and can sometimes even be seen as a threat by those around you, and even to your family. Without support to change, there is a high risk of “failure”.
It critical to acknowledge that this one particular person, the owner of this body, is the only one who can develop and maintain a relationship to his or her body. For those individuals who have developed an identity as an obese person, it is important to see this as a chronic condition. Obesity does not go away; it will always be there, whatever size or weight one is or becomes.
The challenge for society
The need for health care changes over the life-cycle. Interventions such as controlled dieting or bariatric surgery, including aesthetic surgery, should be available, as should health care for comorbidities or complications which might occur. Social services should be available without restriction around obesity care and treatment and otherwise. People need support from health care practitioners to build strength; this will be required intensively in the beginning and will also be necessary on a long-term basis, perhaps for the rest of his or her life.
When obesity is viewed as a chronic disease with all its consequences, one sees that there is also a need to build and maintain a long-term support system around the individual, which includes networks of relevant professionals who can help and support, networks of family and friends, and networks of persons with similar experience. Patients should be involved in the process of obesityrelated research, management and development processes throughout society. This includes developing partnership arrangements that closely match the needs of the individuals and communities.
It is very difficult to build personal strength if you are constantly bombarded with messages about how unworthy you are, how awful you look, etc. To have no access to important parts of society and to have people who should be allies steal health from you by directing these messages towards you is wrong and difficult to cope with. Top importance should be given to eliminating weight stigma that permeates society, through both weight bias within the health field itself and throughout the wider society.
Emphasis on weight loss increases the stigma of obesity and of obese persons who choose different coping strategies – which includes weight acceptance. If we remove the cloud of stigma, people can enjoy walking, dancing, eating well – enjoying nutritious and healthy food, sleeping and being free from the daily stress of socially ordained shame. All of these factors are fundamental for health and well-being and should be the focus for any support system.
Obesity is a multi-factorial issue in a rapidly changing society. Individuals are vulnerable to changes in food production, processing and marketing and to changes in physical work and transportation. Many of these changes are linked to obesity. We need to consider whether obesity in itself is a disease or rather a symptom of a diseased society. We should therefore also look out for and take action on changes in the wider society as well as for individuals.
We want respect. Patients complain that they often are not treated respectfully. This originates from poor knowledge about the disease, even among the obese, about its chronic character, and about the fact that for some people there is no cure for the visible aspect of the disease.
We want acceptance. We want acceptance that obese people are worthy members of our societies and should on all levels be protected from abuse. This could help generate the respect that patients now lack. We need a campaign of respect among politicians, healthcare workers, scientists, media and the obese population itself.
We want recognition. We need recognition that obesity is incurable in the sense that one cannot make a person stop being obese. Consider that 90% of the successfully treated obese remain visibly obese. Realise that even with extensive weight loss, where the condition is no longer obvious from the outside, this identity will be there for the rest of ones’ lives. We need to look at obesity as a chronic and unending social issue.
We want a stop to stigmatisation. The result of the lack of respect enhances stigmatisation, which via separation and bullying in turn leads to discrimination on a personal, national and international level by media, social peers, researchers, health professionals and those in charge of governing schools, cities and countries. We need an action plan for fighting stigmatisation across the entire society.
We want an impartial discussion. Influential stakeholders – industry, media, the economy, insurance companies, governments – all avoid discussion by making the problem increasingly less transparent. Financial costs become a more important issue than the well-being of patients. (Ironically a patient who feels well is less expensive to care for.)
We want shared responsibility. Successful cures, treatments or health programs have not yet been developed and society as a whole must bear the responsibility for this failure. Yet today, it is the obese person who shoulders the entire blame. We should work together for improvements and we need recognition that scientists, clinicians, managers and legislators as well as patients must all be part of the process. Success requires a joint effort. At present we fail together but together we could make a change.
Austria – Simone Posch
Belgium – Elly Jeurissen
Bulgaria – Svetlozara Ilieva
Czech Republic – Alexandra Friasová
France – Anne Sophie Joly
Georgia – Tamar Zerekidze
Germany – Swaantje Memmert
Germany – Björn Brusgatis
Hungary – Judit Pettko
Iceland – Sólveig Sigurðardóttir
Ireland – Vicki Mooney
Italy – Angela Ferracci
Italy – Deborah Loddo
Netherlands – Mieke van Spanje
Poland – Magdalena Gajda
Portugal – Carlos Oliveira
Romania – Silvia Bucur
Sweden – Orley Andreasson
Sweden – Christina Fleetwood
Sweden – Jenny Vinglid
Switzerland – Dominique Durrer
UK – Ken Clare