Jean-Michel Borys

Jean-Michel Borys

General Secretary of the EPODE International Network, France

Ask a child which they like better, brussels sprouts or burgers, and the answer will be a quick one. No question that childhood obesity in the developed countries is increasing on a rapid scale – the question is how we can fight this disease, one of the most serious public health problems of our time and a leading preventable cause of death worldwide. To battle obesity means to battle our mentality: parents, politicians and schools all need to work together to tackle the every-day laziness that makes junk food appear the easiest way to feed a child, says Jean Michel Borys (1960), specialist in Endocrinology, Metabolic Diseases and Nutrition. His holistic concept – a combination of physical activity, nutrition and environmental interventions – has led him to develop Epode, launched to improve the quality and nutritional value of school dinners in France, where it has proven to be so successful that it is now being exported to other countries. Prevention is always the first step in preparing a battle. If you are prepared, we have a meal for you today at this conference – the same that is being served to French schoolchildren on Bory’s initiative. Only without the brussels sprouts. Bon appétit.

Breaking the Wall of Childhood Obesity. What Parents, Politics, and Vegetables Can Do


20 years ago I was in France. The fall of the wall was a great hope for a better world.

I thank the organisers for inviting me to this meeting. It is a great honour for our team to be part of this very special day. Today it will be very difficult to talk about obesity just before lunch, but I will try to meet this challenge. (Laughter in audience). The World Health Organisation predicts that obesity may soon replace more traditional public health concerns, such as undernutrition and infectious diseases as the most significant cause of poor health. Child obesity rates are affecting both developed and developing countries. Now, obesity is a public health and policy problem, because of its prevalence, costs, and health effects.

Obesity is one of the major preventable causes of death worldwide. On this slide you can see that it is the second cause of preventable causes of death in USA- just after smoking. Childhood obesity is a medical condition in which excess body fat has accumulated to the extent that it may affect a child’s health or well being, leading to reduced life expectancy. It is not an appearance or norm issue, but really a health challenge.

The consequences of obesity in childhood are very high. First, emotional and psychological consequences: teasing, stigmatisation, discrimination, low self-esteem, and depression. Second, life-threatening conditions that are associated to childhood obesity: diabetes, heart disease, liver disease, early puberty, eating disorders, skin infections, asthma, and others. Obesity in childhood has social consequences: again, social stigmatisation, disadvantages in employment, more disability leave, less likely to be hired for a job, less likely to be promoted, descendant wedding, limited access to health care, etc.

The socio economic consequences are very important for our societies, and for example it is at least ten percent of all the medical expenditures attributable to obesity in the US today. Obesity is a consequence, but also a source of inequalities. For example, in developed countries, children in higher social class families were less likely to be obese. It is the opposite in the developing world where children in higher social class families have greater rates of obesity.

This is really a global epidemic emerging over the last twenty years. You can see on this slide the prevalence of obesity prior 90s; and the more dark it is, the more the prevalence is higher- ten years later and twenty years later. Maybe more important: in the children, the rate of overweight and obesity dramatically increase since the last twenty years; for example, you have the rates in the USA from 15% to 28%, in England from 7% to 26% or 27%, even in France, Poland, and other countries: Spain, Canada, Brazil, China, India, etc.

Why is there such an evolution? (Shows a picture- laughter) Yes, it is the link with this conference that Michelle Brunet pointed to this morning. I thank you Michelle. Childhood obesity is the result of an interaction between many genetics and environmental factors.

For example, this is one hypothesis: the thrifty gene hypothesis, in which certain ethnic groups may be more prone to obesity in an equivalent environment. Their ability to take advantage of rare periods of abundance by storing energy as fat would be advantageous during times of varying food availability, and individuals with greater adipose reserves would be more likely to survive famine. That is why we are all together in this room today. This tendency to store fat, however, would be maladaptive in societies with stable food supplies like today.

Why such an evolution? The growing problem of overweight and obesity in children is due to an excessive energy intake or a decreasing energy expenditure, which is related to: lifestyle changes, an energy-dense diet and unadjusted to the needs, and a lower time of physical activity and increased sedentary habits on a daily basis. I hope that the next future TV will not be worse for this problem.

It is so complex, and numerous factors and sites which in practice influence the choice of activity and foods by individuals. You can see a graph, which tries to describe all the causes. That means that there is no unique solution to the problem of excess eating and physical inactivity that can be expected.

Concerning the childhood obesity management: today it is diet, exercise, relevant behavioural interventions; today we don’t have any medications currently approved for the treatment of obesity in children. There is the weight loss surgery that relies on reducing the volume of the stomach or reducing the length of bowel that food will be in contact with. But, all these strategies have low effectiveness, and we need today a massive research development.

Why preventing childhood obesity? You have to know that more than 50% of obese children aged 6 today will remain obese later on. More than 75% of the obese children aged 10 will remain obese later on. Disorders related to obesity in adulthood are correlated to its severity and length of evolution. Today, life expectancy is 13 years shorter for a young obese adult aged 18.

Now what is EPODE? EPODE, that is a curious name; that is a name in French that means Ensemble Prévenons l’Obésité Des Enfants. We can translate it as “Together we can prevent childhood obesity”. The most important word is “together”. The EPODE approach is a coordinated, capacity-building approach for communities to implement effective and sustainable strategies to prevent childhood obesity.

Childhood obesity will be reduced by local environments, childhood settings and family norms all being strongly supportive of children enjoying healthy eating, active play and recreation.

In the Epode methodology we have four pillars and goals. The first one is: creating a political commitment. If we want to prevent obesity, we need a very strong political will. This is the first point. The second one is to mobilize resources: human and financial resources. The third is to have coordination and support services. The fourth: to have evidence-based and evaluation for what we are doing. All these four pillars are to enable community stakeholders to implement effective and sustainable strategies to prevent childhood obesity.

The target groups are children aged 0 to 12 years old and their families. Better so, the local stakeholders who can influence childhood settings, food environments and physical activity environments, socio economic policies and socio cultural norms.

Epode is a federative approach. In each country we have what we call the Epode National Coordination in link at the national level with: an Independent Scientific Committee, a National Institutional Support, and with Private Partners. At the local level in link with: the mayors or the elected people elected to represent the community, and these elected people have to nominate what we call the Local Project Manager to manage on the field the actions with a Local Steering Committee and to induce micro-changes in the behaviour of the population of all these targets. What we want to do is the creation of an environment facilitating the adoption of healthier lifestyles by the families.

This is a social mobilisation dynamics at the local level, and all the stakeholders, as you see here, health professionals, but also associations: media, health organizations, school catering, schools, etc. Try to send the same message at the same time to the same target, which is the family.

That is why the town is at the heart of the system. We try to foster multistakeholder dynamics into the towns to change the professional practices, to change the environment of families.

These are some examples of EPODE concrete local actions. The first results are very encouraging, concerning the evolution of overweight and obesity in the cities. You have on this graph the first eight pilot cities in France from 2004 to 2007. You can see, depending on the cities, a decrease from 10 to 15% in the prevalence of obesity and overweight. That is very important in terms of health, but also of cost.

Today, Epode is in France involving 226 towns, in Belgium 15, in Greece, Australia, Mexico, Spain, and we have a grant from the European Commission with the DG Sanco to try to develop the methodology in the 27 countries of Europe. It is a pubic-private partnership, and the cost of the Epode program is about one to two Euros per year and per inhabitant. You have to compare this cost to the cost of the health cost induced by obesity, diabetes, and cardiovascular disease.

In conclusion, it will be my last slide: Obesity is a global epidemic generating long-suffering and individual disabilities. Obesity can be prevented through local, long-term and multistakeholder partnerships at community level. Epode is a community-based approach, based on the creation of an environment facilitating microbehavioural changes toward the adoption of healthier lifestyles by the families. Epode is transferable; it is a methodology- whatever the culture and traditions are.

For the last minute, here is the team in France with Agnés, Christophe, Marianne, Suzy, Julie, Carole, Yann. There you have the contacts and websites. I thank you very much.