Why are we fat?

John C. Peters, Ph.D.

Chief Strategy Officer Anschutz Health and Wellness Center Professor of Medicine

82 Putative Causes
(From the Downey Obesity Report, February 28th, 2013)
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 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 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

Multi-factoral causes

Portion size High energy density High glycemic index Soft drinks/junk food In schools Added sugar Easy food access Low cost Variety Convenience Great taste Ads/marketing Energy intake Energy expenditure

Sedentary
workplaces

Sedentary schools Activity unfriendly

community design

Automobiles Drive-through
conveniences

Elevators/escalators Remote controls Sedentary

WEIGHT GAIN

entertainment

Labor saving devices Television/computer

Obesity: Evolutionary Biology, the Environment, Society and You

The Take Away

Why we are the way we aresurvival

We have built the environment to serve the biology

Obesity is a normal response to the environment

To overcome the biology we will have to rely on cognitionindividual and social

We must find a better why for people and society to change The why must be important for survival in the modern world

The Evolutionary Biology: Why we are the way we are?

Humans are hard wired to like sugar, fat and salt Humans evolved under conditions in which physical activity pulls appetite

We built the environment to Humans are energy misers serve the biology

The biology is not brokenit is doing exactly what it was designed to do

____________________________________ ______

10

Even price has limits

S. French J Nutr 2003

What about physical activity?

A high flux improves regulation of energy balance (and protects against weight gain)

Adapted from Mayer et al, AJCN, 1956

USA Amishtoday

-603 kcal day

-436 kcal day

Obesity rate

0%

9%

32%

35% US Women

Amish Men Amish Women US Men

From Bassett et.al., Med. And Sci. in Sports and Exer., 2004

We dont get enough physical activity

Leisure time physical activity has not declined

Physical activity at work has declined

Physical activity at home has declined

Physical Activity in the USA

2008 Age-Adjusted Estimates of the Percentage of Adults Who Are Physically Inactive

The Evolving Work Force

90.0 80.0 70.0 60.0 50.0

Service Jobs

%
40.0 30.0 20.0 10.0 0.0 1960 1970 1980 Year 1990 2000

Goods Producing Jobs Agricultural 2010 Jobs

Church TS et al. PLoS 2011

Daily Occupational Caloric Expenditure

Occupation Related Daily Energy Expenditure (calories)

Men
1,550

-140 daily kcals

1,450

1,350

Women
1,250

-120 daily kcals

1,150
1960 1970 1980 1990 2000 2010

Year

Church TS et al. PLoS 2011

Trends in Housework Energy Expenditure (1965-2005)

5000 4000

4653

3553

3324

Kcals/week

3000

2769 2877 2806

Women

2000
1000

1452 1013

1923 1977 2086 2034

Men

0 1965 1975 1985 1995 2005 2010

Archer et al. 45-year Trends in Household Management. In Press. PLOS One

We sit too much

Hamilton et al, Curr. Cardiovasc. Risk Reports, 2008

and, its lethal

Over a lifetime, the unhealthful effects of sitting add up. Alpa Patel, an epidemiologist at the American Cancer Society, tracked the health of 123,000 Americans between 1992 and 2006. The men in the study who spent six hours or more per day of their leisure time sitting had an overall death rate that was about 20 percent higher than the men who sat for three hours or less. The death rate for women who sat for more than six hours a day was about 40 percent higher. Patel estimates that on average, people who sit too much shave a few years off of their lives.
New York Times, April 14, 2011

Just say NO to screen time?

One recent study compared adults who spent less than two hours a day in front of the TV or other screen-based entertainment with those who logged more than four hours a day of recreational screen time. Those with greater screen time had:
A nearly 50 percent increased risk of death from any cause About a 125 percent increased risk of events associated with cardiovascular disease, such as chest pain (angina) or heart attack

The increased risk was separate from other traditional risk factors for cardiovascular disease, such as smoking or high blood pressure.
From J Levine, Mayoclinic.com

We are deficient in non-exercise activity thermogenesis (NEAT)

Hamilton et al, Diabetes, 2007

What are the consequences of poor diet, low activity and sitting?
Poor physical and cardiorespiratory fitness Obesity Diabetes Cardiovascular disease Reduced quality of life

Attributable Fractions (%) for All-Cause Deaths

40,842 Men & 12,943 Women, ACLS
18 16 14 12 10 8 6 4 2 0 Men Women

Lo w

CR

Ob es

Sm e

ok er

Hy pe r

te ns io n

Hi gh

Di ab et Ch es ol

Blair SN. Br J Sports Med 2009; 43:1-2.

Humans are biased toward action, not thought (thought is expensive)

The Biology of Choicewe choose for the moment

20 Years

NOW

The marketplace plays to the biology

So What?

What does all of this suggest about ways we might approach the problem differently?

Framework for determinants of physical activity and eating behavior

political advocacy/ lobbying

The Environment and YOU Behavior Settings

food industry transportation system architecture & building codes

Second ary lev erage points Primary leverag e p oints Behavioral settings Lifesty le Enablers o f cho ice exercise, physical activity & sports industry recreation industry Social Cultural Psycho-bio logical Core

food stores family food stores home social trends

local government developers property owners health club workplace community activity providers restaurants and food outlets

health care industry education system entertainment industry

seasonality convenience

restaurants

recreation facilities non-government organizations nonprofit providers

social roles habits life stage self identities pleasure ethnic identities beliefs values interpersonal relationships situation or context physical and social source of information cost time safety accessibility

religious, community and non-government organizations

parks, recreation centers, senior centers community vehicle of transport shopping mall health care providers school board, districts employer

labor-saving device industry information industry government

genetics

hierarchy of needs
physiology

educational attainment

shopping malls

life experience socioeconomic status knowledge local school neighborhood day care

April 20, 20 00

Nutrition Reviews, 59, 2001

The Environment and YOU: Systems

Foresight Diagram

YOU are here

What is the real problem?

Food is cheap

AND, there is no compelling Physical activity is not necessary. reason to change WHY? We are too rich.
Physical activity is not necessary We have disposable income

Godzilla Meets Bambi

BIOLOGY
Unhealthy Preferences

Sugar

Market more fresh produce

Sidewalks, brighter stairwells

Restrictions on bad food Reduced health premiums

Fat
Salt Rest Enjoy

T-shirts, water bottles

AND?

Drive motivation for behavior change by linking desired behaviors to meeting basic needs

Transcendence

Need to move the focus

Self-actualization Esteem Belongingness and Love

Safety and Security

Physiological

Social motivation hierarchy

Transcendence Well Society Collective purpose, American Values, National Pride National defense, affordable housing, safe neighborhoods Economic health, jobs, global competitiveness, education

Strategies for change

Try to structure each behavior environment separately
Continue to focus on individual motivation Leverage a collective motivation across society that is consistent with todays priorities and values Plant the seeds to create demand for a healthier environment

NEW THINKING SPACE

Regulate, mandate, tax, control

Opportunities for healthy choices

Demand for healthy choices (why?)

NEW DOING SPACE

Leave people alone and let them choose

Its about creating demand

Catalyzing demand: Where do we start?

Workplaces

Schools & Home Commerce, the Environment

We need it all
Individual inspiration, for those who are ready to change themselves Environmental structuring, where possible (e.g., schools, workplaces) Nudgechoice architecture, where possible Continued product and service innovation to make healthy behaviors more desirable, accessible, affordable and convenient (supply) A more important WHY for the average citizenas a way to build demand

Summing Up
Changing behavior of individuals or of communities is opposing biological preferences. We built the environment to serve the biology. To manage and work with the biology we need an equally strong cognitive motive that would matter to individuals and society as a whole The WHY should be important for survival in the modern world Sustainable solutions must provide short-term tangible rewards for individuals Sustainable solutions must provide rewards for the social collective, e.g., be integral to the economythe prosperity engine. There is no win-win business model for healthy behaviorsyet

We have changed our environment more quickly than we know how to change ourselves
Walter Lippmann (1915)

Thank You

Thank You