There were no fewer than three contributions on obesity in The Sunday Times of Malta (June 8). It is amazing that the importance of physical activity (i.e. ‘exercise’) was totally omitted.

Exercise was mentioned just once in a disparaging comment by diet guru John Briffa who maintained, wrongly, that “exercise and dieting will not lead to sustained weight loss”. Briffa also hammered carbohydrates as the chief ‘baddy’ in a sweeping condemnation, which presumably included healthy wholegrain stuff such as muesli and porridge.

In any event, the report ‘Weighing in on Obesity’ confirms again that basic concrete measures continue to be sidelined by the proposals of yet more surveys and studies while our waistlines continue to increase.

In the most simple terms possible, people put on weight because they don’t exercise enough and/or overeat fattening foods.

There are some unfortunate people whose overweight problem is ‘in the family’. So let’s be generous and add a third factor: ‘heredity’, which predisposes some people to be overweight. Though it is now believed that the effect of this genetic factor is weakened by exercise; this gives further emphasis to the importance of exercise in approaching the obesity problem.

As stated in the article, the steady increase in obesity has occurred during the last 30 years. It is hardly likely that our genes have changed in that short time. In other words, pace Briffa, our “hormones, biochemistry and physiology” remained exactly the same as they were 50 million years ago.

Neither can we blame ‘traditional Maltese foods’. Not much has changed there either; we feasted just as much in the past on ‘traditional’ pastizzi, roast macaroni, timpana, spaghetti and numerous gigantic pastry dishes followed by sticky sugar-laden desserts.

Overindulgence has been with us long before the obesity epidemic started. We also used to drink gallons of sugar-laden ‘Orangora’ ‘Lemonora’ and colas. We may have replaced some of our traditional food with modern fast food stodge but, on balance, our diet still has much the same pattern.

So where does the cause of the current obesity tsunami lie? The answer must be that we now move less.

The unprecedented escalation of obesity during the last 30 years coincides neatly with the advent of almost universal car ownership and passive sedentary behaviour associated with technology.

This is compounded by the obesogenic influences from the ongoing process of urbanisation and degradation of our environment. This has transformed our way of life and tipped the energy balance towards obesity.

WHO explicitly states that supportive environment and communities are fundamental in shaping people’s choices by making healthier lifestyles and diet options affordable and easily accessible.

The health organisation also emphasises that policymakers should create healthy environments to counter obesity.

The obesity epidemic has also spread to children. Malta’s record childhood obesity rates are mostly environmentally determined. Our children rarely walk, meet, socialise with other children or play in residential streets . They grow up isolated in bubble packing, imprisoned at home by our hostile street environment. They are reduced to passively watching, on average, about three hours of television daily – in addition to playing games on computers.

Our children are growing up conditioned to car dependency through being driven everywhere by their parents from an early age. Youngsters don’t ride bicycles anymore or ride to school, as is common in sophisticated countries – they are prevented by their parents from cycling, sometimes even from walking in streets because of the danger from traffic.

WHO emphasises that children’s choices, diet and physical activity habits are influenced by their surrounding environment and that, in addition to dietary factors, transport, urban planning and environment, are promoting unhealthy weight gain, leading to a steady rise in the prevalence of childhood obesity.

Malta has one of the highest levels of car ownership in the EU. There is nothing inherently wrong with car ownership, but we depend excessively on our car to the exclusion of other healthy mobility options.

Countries in which people walk more and where bicycle transport has become synonymous with progress and modernity don’t have an obesity programme. For instance, Holland has a higher car ownership rate than Malta. Yet, nationwide, 25 per cent of daily journeys are made on foot and 27 per cent by bicycle.

In Amsterdam 60 per cent of all journeys are made by bicycle. By contrast, the UK and the US have the lowest percentage of trips on foot or bicycle of all the western developed countries. Walking and cycling data are not available for Malta, but excessive car dependency must be the chief suspect here – as in the UK and the US.

And things don’t seem to be looking up. Urban overdevelopment continues, pavements get narrower to make space for traffic, while high priority continues to be given to motorised traffic flows with policies of nationwide creation of more parking facilities and implementation of traffic management schemes.

Too many children are growing up conditioned to car dependency through being driven everywhere

These simply encourage more car dependence. So our streets become more hostile to pedestrians and less ‘walkable’ as a result of heavier traffic. They remain dangerous to vulnerable road users, especially the aged and children.

The end result is that people walk less and must rely exclusively on the car. Creating sports facilities and subsidising health gym membership are not the answer either because they only address the few who are well-motivated – these are unlikely to be obese in the first place.

In addition to badly needed dietary measures, we need to add a new perspective which focuses with equal urgency on environmental prevention by implementing public health measures which encourage adequate exercise and what is now collectively referred to as ‘active mobility’.

Policies aimed at reducing the dominance of the car and making transit on foot or bicycle attractive, safe and convenient are needed.

Measures include modernising our roads and streets to bring them in line with current philosophies and concepts to encourage incorporation of active mobility and physical activity in our daily routine.

These would include urban traffic calming, discouraging car use by creating urban car-free zones, prohibition of urban through-traffic, imposing low (20/30km/h) speed limits and cycle tracks or lanes on commuting routes.

We must turn to modern (urban/residential) street designs with extensive shared spaces and to the creation of residential home zones in which people – especially children and the aged – feel safer and more inclined to walk.

There must be additional enforcement policies that favour safety of pedestrians and cyclists over motorists; this would include the introduction of a law of presumed liability as in many EU countries.

The ultimate objective should be based on the premise that physical activity generated by active mobility results in substantial amounts of energy expenditure, if performed regularly and built into the daily routine.

This has been shown to be effective not only in weight control but also in conferring a host of other physical and mental health benefits through improved fitness – including a lowered susceptibility to dementia.

No amount of well-intentioned efforts by health professionals are likely to make a sufficient impact as long as our (urban) roads and streets remain dismal traffic-congested spaces which do not invite pedestrians to use them.

Remaining as we are will hinder attempts to reduce our rampant obesity and threaten to cancel out many of the gains that have been made through advances in medicine and decrease in tobacco use. This is compounded by the pollution generated by our heavy traffic.

While radical changes are taking place in many countries, things remain the same in Malta where roads continue to be traffic spaces and not people spaces.

These issues are largely discussed in the think-tank reports Healthy Mobility in Sliema: A Case Study and parts II and III of Towards a Low Carbon Society: The Nation’s Health, Energy Security and Fossil Fuels.

George Debono is a medical doctor. He is now retired and is a board member of the Today Public Policy Institute think tank ( http://www.tppi.org.mt )

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