EPODE – A Model for Reducing the Incidence of Obesity and Weight-related Comorbidities

European Endocrinology, 2013;9(2):116–20 DOI: http://doi.org/10.17925/EE.2013.09.02.116


Obesity is a global epidemic: it is estimated that the majority of the world’s adults will be overweight or obese by 2030. It is therefore important to reverse trends towards increasing childhood obesity by interventions at the community level. Ensemble Prévenons l’Obésité Des Enfants (EPODE, Together Let’s Prevent Childhood Obesity) is a large-scale, coordinated, capacity-building approach for communities to implement effective and sustainable strategies to address this challenge. EPODE comprises four critical components: political commitment, public and private partnerships, community-based actions, and evaluation. The multi-stakeholder approach promoted through the EPODE methodology has already shown encouraging results in preventing childhood obesity in France and Belgium and has reduced the socioeconomic gap in obesity prevalence in France. The EPODE methodology has now been implemented in a number of countries worldwide, and provides a valuable model that may be applicable to other lifestyle-related diseases.
Keywords: Childhood obesity, community-based interventions, EPODE, overweight
Disclosure: The authors have no conflicts of interest to declare.
Received: March 18, 2013 Accepted May 18, 2013
Correspondence: J-M Borys, 109–111 Rue Royale, 1000 Brussels, Belgium. E: jmborys@epode.be
Support: The publication of this article was supported by The Coca-Cola Company. The views and opinions expressed are those of the authors.

The prevalence of overweight and obesity has increased worldwide over the last 30 years. 1–5 It was estimated that in 2005, 23.3 % of the world population was overweight and 9.8 % was obese 6 and in 2009–10, 37 % of adults in the US and almost 17 % of youths were obese. 7 Predictions concerning overweight and obesity prevalence suggest that the majority of the world’s adults will be overweight or obese by 2030. In the US, it is estimated that 86.3 % of adults will be overweight and 51.1 % will be affected by obesity.8 Obesity and its associated health risks involve direct and indirect economic costs that impact significantly on healthcare systems. In the US, these costs were estimated at $147 billion in 2008. Heathcare costs are predicted to double every decade, reaching about $956.9 billion in 2030. 9 There is, therefore, a critical need for global strategies to prevent obesity. A growing body of evidence shows that prevention through a lifestyle modification in eating habits and physical activity is one of the most efficient and cost-effective ways to tackle the obesity epidemic. 10 Furthermore, lifestyle modification is associated with substantial risk reductions for metabolic diseases; a recent epidemiological study found that individuals undertaking regular physical activity had a reduced risk for Type 2 diabetes (T2D): odds ratio (OR) 0.76 for men (95 % confidence interval [CI] 0.73–0.79) and 0.77 for women (95 % CI 0.73–0.82).11 In order to be effective, public interventions for the prevention of obesity should be implemented in three stages: targeting entire populations, high-risk subgroups of the population and individuals at high risk. This may be undertaken at national, state and community levels, and should involve numerous sectors, such as childcare facilities, schools, workplaces and seniors centres. A focus on specific populations may be required to ensure that interventions address disparities in social and environmental conditions related to food consumption and physical activity. A positive correlation has been demonstrated between low-socioeconomic status and obesity. A review of studies conducted in 13 EU member states suggested that over 20 % of the obesity in European men and over 40 % of the obesity in women was attributable to socioeconomic inequalities. In addition, obesity among children was associated with the socioeconomic status of their mothers.12 Public interventions targeting obesity have had varying degrees of success; however, a community-based intervention, the Fleurbaix Laventie Ville Santé Study (FLVS), demonstrated significant reductions in the prevalence of both overweight and obesity and in health inequalities. 13 This longterm intervention pilot programme formed the basis of the Ensemble, Prévenons l’Obésité des Enfants (EPODE) methodology, disseminated today in more than 17 countries. This article’s aim is to outline the EPODE methodology, to discuss its potential for transferability, and to suggest ways in which EPODE may be used as a model for future strategies to reduce the global incidence of other weight-related comorbidities. Health Effects of Overweight and Obesity Overweight and obesity in childhood are known to have significant impacts on both physical and psychological health and both are associated with abnormal glucose tolerance and an increased risk of T2D. Moreover, adipose tissue releases non-esterified fatty acids, glycerol, hormones and pro-inflammatory cytokines, all of which are associated with the development of insulin resistance.14 T2D has become a global epidemic and is associated with increased risk of cardiovascular disease (CVD) and premature mortality. Between 1980 and 2006, the number of adults with T2D rose from 153 million to 347 million worldwide.15 Obesity and overweight can result in numerous other adverse health outcomes, including dyslipidaemia, hypertension, coronary artery disease, certain cancers, sleep apnoea and an increased risk of mortality.16 In children, overweight has been associated with T2D, sleep apnoea, hypertension, dyslipidaemia, the metabolic syndrome and psychological disorders such as depression.17 Overweight children subsequently monitored in later life had increased incidence of CVD, digestive diseases and all-cause mortality compared with those who were lean.18,19
1. Lissau I, Overpeck MD, Ruan WJ, et al., Body mass index and overweight in adolescents in 13 European countries, Israel, and the United States, Arch Pediatr Adolesc Med, 2004;158:27–33.
2. Spurgeon D, Childhood obesity in Canada has tripled in past 20 years, BMJ, 2002;324:1416.
3. Kalies H, Lenz J, von Kries R, Prevalence of overweight and obesity and trends in body mass index in German preschool children, 1982-1997, Int J Obes Relat Metab Disord, 2002;26:1211–7.
4. Wang Y, Lobstein T, Worldwide trends in childhood overweight and obesity, Int J Pediatr Obes, 2006;1:11–25.
5. Lobstein T, Frelut ML, Prevalence of overweight among children in Europe, Obes Rev, 2003;4:195–200.
6. Kelly T, Yang W, Chen CS, et al., Global burden of obesity in 2005 and projections to 2030, Int J Obes (Lond), 2008;32:1431–7.
7. Ogden C, Carroll MD, Kit BK, et al., Prevalence of obesity in the United States, 2009–2010, NCHS Data Brief, 2012;1–8.
8. Wang Y, Beydoun MA, Liang L, et al., Will all Americans become overweight or obese? estimating the progression and cost of the US obesity epidemic, Obesity (Silver Spring), 2008;16:2323–30.
9. Finkelstein EA, Trogdon JG, Cohen JW, et al., Annual medical spending attributable to obesity: payer-and service-specific estimates, Health Aff (Millwood), 2009;28:w822–31.
10. Kumanyika S (editor), Bridging the Evidence Gap in Obesity Prevention: A Framework to Inform Decision Making, Institute of Medicine, 2010.
11. Reis JP, Loria CM, Sorlie PD, et al., Lifestyle factors and risk for new-onset diabetes: a population-based cohort study, Ann Intern Med, 2011;155:292–9.
12. Robertson A, Lobstein T, Knai C, et al., Obesity and socioeconomic groups in Europe: Evidence review and implications for action (available at: http://ec.europa.eu/ health/ph_determinants/life_style/nutrition/documents/ ev20081028_rep_en.pdf) 2007.
13. Romon M, Lommez A, Tafflet M, et al., Downward trends in the prevalence of childhood overweight in the setting of 12-year school- and community-based programmes, Public Health Nutr, 2009;12:1735–42.
14. Kahn SE, Hull RL, Utzschneider KM, Mechanisms linking obesity to insulin resistance and type 2 diabetes, Nature, 2006;444:840–46.
15. Danaei G, Finucane MM, Lu Y, et al., National, regional, and global trends in fasting plasma glucose and diabetes prevalence since 1980: systematic analysis of health examination surveys and epidemiological studies with 370 country-years and 2.7 million participants, Lancet, 2011;378:31–40.
16. Poirier P, Giles TD, Bray GA, et al., Obesity and cardiovascular disease: pathophysiology, evaluation, and effect of weight loss: an update of the 1997 American Heart Association Scientific Statement on Obesity and Heart Disease from the Obesity Committee of the Council on Nutrition, Physical Activity, and Metabolism, Circulation, 2006;113:898–918.
17. Daniels SR, Arnett DK, Eckel RH, et al., Overweight in children and adolescents: pathophysiology, consequences, prevention, and treatment, Circulation, 2005;111:1999–2012.
18. Mossberg HO, 40-year follow-up of overweight children, Lancet, 1989;2:491–3.
19. Must A, Jacques PF, Dallal GE, et al., Long-term morbidity and mortality of overweight adolescents. A follow-up of the Harvard Growth Study of 1922 to 1935, N Engl J Med, 1992;327:1350-5.
20. Borys J-M, Le Bodo Y, De Henauw, S, et al., Preventing childhood obesity. EPODE European Network Reccomendations. (Available at: http://www.epodeinternational- network.com/sites/default/files/EEN_ BOOK.pdf) 2011.
21. Borys JM, Le Bodo Y, Jebb SA, et al., EPODE approach for childhood obesity prevention: methods, progress and international development, Obes Rev, 2012;13:299–315.
22. Romero-Corral A, Somers VK, Sierra-Johnson J, et al., Accuracy of body mass index in diagnosing obesity in the adult general population, Int J Obes (Lond), 2008;32:959–66.
23. WHO, The Challenge of obesity in the WHO European Regions and the strategies for responses. (Available at: http://www.euro.who.int/__data/assets/pdf_ file/0008/98243/E89858.pdf) 2007.
24. Huang TT, Yaroch AL, A public-private partnership model for obesity prevention, Prev Chronic Dis, 2009;6:A110.
25. Kraak VI, Story M, A public health perspective on healthy lifestyles and public-private partnerships for global childhood obesity prevention, J Am Diet Assoc, 2010;110:192–200.
26. Buse K, Walt G, Global public-private partnerships: Part I—A new development in health?, Bull World Health Organ, 2000;78:549–61.
27. OECD, Shaping the 21st Century: The Contribution of Development Cooperation. (Available at: http://www.oecd. org/dac/2508761.pdf) 1996.
28. Kickbusch I, Quick J, Partnerships for health in the 21st century, World Health Stat Q, 1998;51:68–74.
29. EIN, EIN Press Release: Epode International Network applauds Ontario’s Healthy Kids Panel Report, 2013.
30. Borys J-M, Encouraging results in French EPODE Pilot towns, EEN Newsletter N°5 – September 2010.
31. Preventing childhood obesity involving local stakeholders in a sustainable way: the VIASANO programme, ECOG Congress abstract, 2010.
32. EEN, EEN press release: 22% fewer overweight children in nursery schools in Belgium thanks to the VIASANO programme. (Available at: http://www.epode-internationalnetwork. com/sites/default/files/EIN_Viasano_ PressRelease.pdf) 2012.
33. Kumanyika SK, Obarzanek E, Stettler N, et al., Populationbased prevention of obesity: the need for comprehensive promotion of healthful eating, physical activity, and energy balance: a scientific statement from American Heart Association Council on Epidemiology and Prevention, Interdisciplinary Committee for Prevention (formerly the expert panel on population and prevention science), Circulation, 2008;118:428–64.
34. Katan MB, Weight-loss diets for the prevention and treatment of obesity, N Engl J Med, 2009;360:923–5.
35. Dubois L, Girard M, Early determinants of overweight at 4.5 years in a population-based longitudinal study, Int J Obes (Lond), 2006;30:610–17.
36. Kopczynsk IM, Pritchard K, The Use of Evaluation by Nonprofit Organizations, In: Wholey J (ed.) Handbook of Practical Programme Evaluation, San Francisco, CA: Jossey-Bass, 2004;649–69.
37. WHO EWGoHPE, Health Promotion Evaluation: Recommendations to Policy-Makers: Report of the WHO European Working Group on Health Promotion Evaluation. Copenhagen, Denmark: World Health Organization, Regional Office for Europe. (Available at: http://www.euro. who.int/__data/assets/pdf_file/0004/159871/E60706. pdf) 1998.
38. Al-Maskari F, Lifestyle Diseases: an economic burden on the health services, UN Chronicle. (Available at: http:// www.un.org/wcm/content/site/chronicle/lang/en/ home/archive/issues2010/achieving_global_health/ economicburdenonhealthservices) 2010.
39. WHO, Population-based prevention strategies for childhood obesity – Report and technical meeting. Report of the WHO forum and technical meeting. (Available at: http://www.who. int/dietphysicalactivity/childhood/child-obesity-eng.pdf) 2009.
Keywords: Childhood obesity, community-based interventions, EPODE, overweight