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For some time, clinicians have recognized that people with obesity have a great deal of backache and are far more prone to osteoarthritis of the weight‐bearing joints. It was also well known that weight gain exacerbates hypertension and hypercholesterolemia as well as promoting glucose intolerance and then diabetes. These hazards of obesity were usually presented as a consequence of self‐inflicted weight gain, so they were not taken seriously by many clinicians and were even viewed as a means by which one could persuade patients to be slim. However, a more considered understanding of the role of obesity in health was obtained from the WHO Millennium Review of Health conducted by Alan Lopez with Chris Murray and colleagues, which summarized for the first time the amount of death and disability in each of the 14 subregions of the world that was attributable not to particular diseases but to avoidable risk factors. This allowed for much more meaningful public health policy making and led in 2002 to WHO’s report on reducing risks globally [72]. The risk factors considered included iron deficiency anemia and vitamin A deficiency as well as childhood and maternal malnutrition, high cholesterol levels, and high blood pressure. The IOTF was asked to undertake the work on global rates of overweight and obesity for this analysis. The relationship of obesity with a host of other diseases, for example arthritis, cardiovascular disease, cancers, and diabetes, was quantified, and all these relationships together with all the other risk factors were linked to data on premature death (i.e. <75 years) and to years of disability. In this analysis, overweight and obesity were ranked the 7th most important risk factor for premature death on a global basis and the 10th most important factor in terms of disability [73]. Since then, overweight and obesity prevalences have escalated, and Murray’s team based in Seattle with Gates Foundation support has established an annual analysis of disease burden and risk factors which are published regularly by The Lancet. The assessment of the burden of disease in 2017 found a 43% increase in the global male prevalence of overweight (i.e. BMI 25+) from 1990, and in women, the increase was 67% [74]. More detailed analysis of obesity per se came from a special sub‐study with the burden being calculated again as a composite of years of life lost because of weight gain and years of life lived with disabilities linked to excess weight, as shown in Figure 1.5 [75]. Note that the figures include both years of life lost and the years of earlier disabilities. The greatest burden arises from the excess cardiovascular disease induced by excess weight gain, with kidney disease and diabetes being the next two major burdens. However, the authors recognize that the risk increases from about a BMI of 20, and the major finding is that a substantial burden is induced by just being overweight and not obese. In fact, the overweight burden amounts to about a third of all the burden of obesity and actually accounts for nearly 40% of premature deaths related to excess weight gain. This means that in public health terms, one cannot forget about the large proportion of adults who are overweight. Even with modest increments of risk, their high prevalence means that the overweight group contributes a substantial disease burden.

Figure 1.5 The global burden of disease assessed in terms of disability‐adjusted life years (DALYs) in millions, which includes the years of life lost due to premature mortality plus the years lived with a disability from the range of different disorders listed.

(Source: Redrawn from Figure 1.3b in the global burden analyses [75].)