Obesity: The Current Landscape James O. Hill, Ph.D. Anschutz Professor Executive Director Anschutz Health and Wellness Center University of Colorado
Obesity: The Current Landscape
James O. Hill, Ph.D.Anschutz ProfessorExecutive Director
Anschutz Health and Wellness CenterUniversity of Colorado
Obesity Issues 2013
• Why are we so fat?• Why do we care?• What can we do about it?
• Role of the environment• National Security Issue• Role of Industry• Kids• What should we be talking about
The Obesity Solution
How Fat are We?
Overweight
Obese
Extremely Obese
Note: Age-adjusted by the direct method to the year 2000 US Bureau of the Census using age groups 20-39, 40-59 and 60-74 years. Pregnant females excluded. Overweight defined as 24,=BMI; obesity defines as BMI>=30; Extreme obesity defines as BMI>=40.
Trends in overweight, obesity and extreme obesity, ages 20-74 years
Age 12-19
Age 6-11
Age 2-5
Note: Overweight is defined as BMI>=gender and weight-specific 95th percentile from the 2000 CDC Growth Charts. Source: National Health Examination Surveys II (ages 6-11) and III (ages 12-17), National Examination Surveys, I, II, III and 1999-204, NCHS, CDC.
Trends in child and adolescent overweight
What Causes Obesity?
• Name the top 3 causes of obesity
Potential Causes of Obesity
• 1. agricultural policies• 2. air conditioning,• 3. air pollution,• 4. antibiotic usage at early age• 5. arcea nut chewing,• 6. assortative mating,• 7. being a single mother,• 8. birth by C-section,• 9. built environment,• 10. chemical toxins,• 11. child maltreatment,• 12. competitive food sales in schools,• 13.
consumption of pastries and chocolate (in Burkina Faso),
• 14. decline in occupational physical activity,
• 15. delayed prenatal care,• 16. delayed satiety,
• 17. depression• 18. driving children to school• 19. eating away from home• 20. economic development• 21. endocrine disruptors,• 22. entering into a romantic relationship
,• 23. epigenetic factors,• 24. family conflict,• 25. first-born in family• 26. food addiction• 27. food deserts• 28. food insecurity,• 29. food marketing to children• 30. food overproduction• 31. Friends• 32. genetics,• 33. gestational diabetes,• 34. global food system,
Potential Causes of Obesity
• 35. grilled foods• 36. gut microbioata,• 37. having children, for women,• 38. heavy alcohol consumption,• 39. home labor saving devices,• 40. hunger-response to food cues,• 41.
international trade policies (globalization)• 42. high fructose corn syrup,• 43. lack of family meals,• 44. lack of nutritional education,• 45. lack of self-control,• 46. large portion sizes,• 47. living in the suburbs,• 48. living in crime-prone areas,• 49. low levels of physical activity,• 50. low socioeconomic status,• 51. market economy,• 52. marrying in later life
• 53. maternal employment,• 54. maternal obesity,• 55. maternal over-nutrition during pregnancy,• 56. maternal smoking,• 57. meat consumption,• 58. menopause,• 59. mental disabilities,• 60. no or short term breastfeeding,• 61. non-parental childcare• 62. overeating,• 63.
participation in Supplemental Nutrition Assistance Program (formerly Food Stamp Program)
• 64. perception of neighborhood safety,• 65. physical disabilities,• 66.
prenatal maternal exposure to natural disasters,
• 67. poor emotional coping• 68. sleep deficits,• 69. skipping breakfast,• 70. snacking,
Potential Causes of Obesity
• 71. Smoking Cessation,• 72. stair design• 73. stress• 74. sugar-sweetened beverages,• 75. trans fats,• 76. transportation policies,• 77. television set in bedrooms• 78. television viewing,• 79. thyroid dysfunction• 80. vending machines,• 81. virus• 82. weight gain inducing drugs.
Which of these factors have been changed to impact obesity?
How do we begin to study the problem?
The Energy Balance System
Energy Intake
Energy Expenditure
EnergyStores
Active Regulation/Integration
InheritedFactors
EnvironmentalFactors
•Efficiency•Adaptive thermogenesis•Food preferences
•Food environment•Physical activity environment
DecreaseEnergyIntake
Body weight increases
Body weight does not change
Body weight decreases
Usual physical activityMetabolic RateFood Intake
What happens to body weight when food intake is decreased?
IncreasePhysicalActivity
Body weight increases
Body weight does not change
Body weight decreases
Usual physical activityMetabolic RateFood Intake
What happens to body weight when physical activity is increased?
EInEOut
BodyWeight
Active RegulationThe obesity epidemic arose fromgradual weight gain over time
Which is more important – food or phsical activity?
1971-74 1976-80 1988-94 1994-20001000
1100
1200
1300
1400
1500
1600
1700
1800
1900
2000
130
135
140
145
150
155
160
Energy Intake (kcal/day) Body Wt (lbs)Women
TS Church, PLoS One 2011;6(5):e19657.
Why are we gaining weight? Occupations and Obesity
18000
14000
5940 5276
Steps per Day
US Men US Women
Walking: Old Order Amish vs. Current Population
Amish Men Amish Women
~603 kcal/day
~436Kcal/day
Energy Intake
Energy Expenditure
Obesity
Body Weight
Energy Intake
Our biology works best at high
Physical Activity Threshold for Optimal Weight Regulation
“Unregulated” Zone
“Regulated” Zone
Metabolic Changes with Decreased Physical Activity
MusclesInsulin SensitivityNutrient MetabolismFat CellsAppetiteBrain function
Hypothetical Model for the Cause of the Obesity Epidemic of the Late 20th Century
Total Energy expenditure
EnergyExpenditure inPhysical Activity
Body Weight
Energy Intake
198019501920 2013
Role of the Environment?
Addressing the Environment
How do we reduce obsity?
The Energy Balance System
Energy Intake
Energy Expenditure
EnergyStores
Active Regulation/Integration
EnergyGap
-10% (10 kg) = 190-200 kcal/day
-15% (15kg) = 280-300 kcal/day
EnergyGap
Obesity
How much behavior change is needed forsuccessful weight loss maintenance?
Example for 100 kg person
Comparison of weight loss diets with different compositions of fat, protein and carbohydrates (n=811)
Sacks FS. et al. NEJM 2009;360(9) 859-873.
Characteristics of Successful LosersNational Weight Control Registry
1.Eating a Reduced Calorie-Reduced Fat Diet
2.Engaging in a high level of physical activity
3.Limiting TV Viewing4.High level of dietary restraint5.Frequent self-weighing6.Maintaining dietary consistency 7.Eating breakfast
BodyWeight
EnergyGap
EnergyGap
EnergyGap
Healthy Weight
Overweight
Obese
Energy Gap for Prevention of Weight Gain(<100 kcal/day)
The birth of small changes
Biology Behavior
Environment
Addressing Obesity
Biology
• Desire to Eat•Pref for sweet/fat•No Drive to be active
FoodAvailableGood tastingEnergy denseInexpensiveLarge portions
Physical ActivityLittle need for physical activity in daily livingAttractiveness of sedentary EntertainmentCar for Transportation
Economics•Consume More•More for less•Greater Productivity
DecreasedEnergy Expenditure
IncreasedEnergy Intake
Obesity
Social Systems
Reason to push back
Different Value Equation
Social Environment of Wellness
HealthyEnvironment
Make better choices
Biology, Behavior & Environment
20 years
NOW
What’s Missing: the Why
Role for the private sector?
Ideas
basic and clinical research
Programs evaluated in controlled settings
Development ofScience-based programs
Implement ProgramsIn the population
How Academia Works
Goal: Use science to improve people’s lives
Ideas
basic and clinical research
Programs evaluated in controlled settings
Development ofScience-based programs
Implement ProgramsIn the population
Industry Involvement in Implementation
Diabetes Prevention Program (DPP) 2002
Ideas
basic and clinical research
Programs evaluated in controlled settings
Development ofScience-based programs
Implement ProgramsIn the population
Diabetes Prevention Program (DPP)
Lifestyles factors and glycemic control
May be possible to prevent diabetes in those at risk
Small scale testingof impact of lifestyle
DPP
??
Ideas
basic and clinical research
Programs evaluated in controlled settings
Development ofScience-based programs
Implement ProgramsIn the population
Menu Labeling
Knowing calorie content could reduce intake
Very little clinical research
No real testing
Very little evaluation in controlled settings
Policy to force implementation
Colorado Center for Health & Wellness Center
Health &Wellness
Clinical
EducationResearch
Addressing a Complex Issue
Private Sector PartnershipsCommunity Engagement
Create new “thinking space” for creating solutions
Develop and TestPotential Solutions
ImplementScience-Based,Scalable Programsand Initiatives
Enjoy the next 3 days