Perspective Obesity

TRIGGERS OF THE OBESITY EPIDEMIC

The Obesity Epidemic: A Consequence of Reduced Energy

Expenditure and the Uncoupling of Energy Intake?
Timothy Church1,2 and Corby K. Martin1

Obesity prevalence has increased, and increased energy intake or decreased physical activity are the two
most obvious contributing factors. The percentage of Americans engaging in exercise has been stable
over the past few decades, but decreases in occupation-related energy expenditure are sufficient to par-
tially explain increased obesity prevalence. Further, the contribution of energy intake and energy expendi-
ture to the obesity epidemic is complicated because they are not independent—they are influenced by
each other. For example, Mayer found that low activity levels were marked by higher body weight and
higher “unregulated” energy intake levels. Conversely, higher activity levels were marked by lower body
weight and energy intake that matched energy expenditure. Consistent with Mayer, we propose that
because most Americans have low levels of occupation-related activity, they do not benefit from the regu-
lation of energy intake achieved at higher activity levels, resulting in weight gain due to energy intake
exceeding energy expenditure.
Obesity (2018) 26, 14-16. doi:10.1002/oby.22072

There are three distinct phases in the weight gain–loss continuum:
initial weight gain, weight loss, and weight loss maintenance. The
underlying physiology of each phase is unique, including the relative
contribution of energy intake and energy expenditure. Of the three
phases, weight loss is the best understood, with caloric intake having
a much larger influence on active weight loss than exercise (1). For
weight loss maintenance, it is widely stated that regular exercise is
critical to keeping weight off after the active weight loss phase (2).
The data supporting this assertion are largely post hoc, and to date,
there have been no large properly powered trials that have specifi-
cally examined the role of exercise in helping to maintain weight
loss. We have demonstrated that, in many individuals, increased
exercise results in increased energy intake, a phenomenon known as
compensation (3). From a clinical perspective, there is a great need
to better identify individuals who will negatively respond to
increased exercise and concomitant increases in energy expenditure.
The least understood of the three phases of the weight gain–loss
continuum is the weight gain phase. This lack of understanding is
surprising, given the importance of avoiding weight gain in the first
place, as it is very clear that once weight is gained, the human body
will physiologically defend the new weight (4). The popular consen-
sus is that the increase in the variety, availability, and caloric den-
sity of the food supply has driven population-wide increases in
caloric intake and the obesity epidemic in general (5). Given the
plethora of best-selling books, media coverage, and obviousness of
this argument, it is not hard to appreciate how this has become a
generally accepted belief. However, the longitudinal data to support
the food supply characteristics driving the obesity endemic are
remarkably weak, particularly given the magnitude of public health
importance this issue presents.
The relative contribution of changes in physical activity to the obe-
sity epidemic is largely dismissed because of the undeniable obser-
vation that the percentage of Americans participating in regular
exercise has not changed over the past few decades (5). However,
this dismissive argument ignores the fact that formal exercise plays
a very small role in the total daily physical activity energy expendi-
ture. Total energy expenditure is driven by total daily activity,
which is primarily determined by occupation.
The federal government tracks yearly the types of jobs Americans
fill, and the Occupational Safety and Health Administration does a
remarkable job of assigning energy expenditure requirements to all
jobs. We took advantage of these data sources to examine how
trends in work-related physical activity and energy expenditure from
1960 to 2006 have impacted population-wide weight gain (6). We
observed that in the 1960s, 50% of individuals had a job that
required a level of physical activity that would meet the current
daily physical activity goals (Figure 1). We estimated that by 2006
less than 20% of Americans had jobs that required this level of
physical activity. And this is likely a large underestimation, as we
were not able to take into account technological efficiencies in this
analysis and only focused on job categories. We estimated a pro-
gressive loss of 100 to 150 calories per day, and this reduction in
energy expenditure produced an estimated population-based weight
gain that closely matched the National Health and Nutrition Exami-
nation Survey’s measured weight over the years (Figure 1). We are

1 2
Pennington Biomedical Research Center, Baton Rouge, Louisiana, USA. Correspondence: Timothy Church (Timothy.Church@pbrc.edu) ACAP Health,
Dallas, Texas, USA.

Disclosure: The authors declared no conflict of interest.

Received: 12 September 2017; Accepted: 4 October 2017; Published online 20 December 2017. doi:10.1002/oby.22072

14 Obesity | VOLUME 26 | NUMBER 1 | JANUARY 2018 www.obesityjournal.org

Perspective
TRIGGERS OF THE OBESITY EPIDEMIC
Figure 1 The red line represents the decrease in daily occupational energy expenditure from 1960 to 2010 for
men. The orange bars represent the expected mean body weight of men in the United States based on
decreases in energy expended via occupations. The blue bars represent the mean body weight for men from the
National Health and Nutrition Examination Survey. Adapted from Church et al. (6).
Figure 2 The blue line represents the J-shaped association between energy
expenditure and energy intake in which energy intake matches energy expenditure
at higher levels of energy expenditure but not at lower levels of energy expenditure.
The red line represents body weight. At high levels of energy expenditure, weight is
controlled because of the relation between energy expenditure and energy intake.
At low levels of energy expenditure, however, weight is increased because of
higher levels of energy intake in the context of low levels of energy expenditure.
Adapted from Mayer et al. (9).
not the first to demonstrate that a relatively small change in energy
balance could explain the obesity epidemic (7). We appreciate that
our findings are provocative, and it is very important to point out
that we do not believe that work-related physical activity is entirely
responsible for the obesity epidemic. The primary point is that it is
unlikely that changes in the food supply can alone account for the
obesity epidemic, and changes in daily activity are likely an impor-
tant part of this conversation.
As noted earlier, energy expenditure and energy intake are not inde-
pendent physiological systems but rather are intimately connected.
www.obesityjournal.org
Obesity
From an evolutionary perspective, it makes sense that there is a
strong physiological drive to match caloric intake to caloric expendi-
ture. This is supported by Bassett et al.’s study of an agrarian Amish
community in which it was observed that high levels of work-
related physical activity were accompanied by high levels of energy
intake but very low levels of obesity (8). The very high levels of
daily energy expenditure of the Amish population did not allow for
examination of energy intake in sedentary subgroups. Mayer et al.
studied the associations of work-related physical activity, weight,
and energy intake across a wide range of activity levels (9). They
too found that at moderate-high levels, energy expenditure closely
matched energy intake and that there was a low prevalence of over-
weight in these individuals. Conversely, at low levels of energy
expenditure, the association between energy expenditure and energy
intake were disrupted, with high levels of energy intake accompany-
ing low levels of activity and elevated weight. As depicted in Figure
2, Mayer et al. proposed a J-shaped association between energy
expenditure and energy intake, in which energy intake matches
energy expenditure at higher levels of energy expenditure. But at
low levels of energy expenditure, this tight association is disrupted
and high levels of energy intake persist, resulting in weight gain.
We propose that the current very low levels of occupation-related
physical activity have pushed the majority of Americans into the
unregulated zone of Mayer’s curve. And this, combined with the
modern food environment, has created a toxic interaction responsible
for the current obesity epidemic.
Given the body’s resistance to weight loss once weight is gained,
the importance of preventing weight gain cannot be overstated.
There is a critical need to better understand the broader determinants
of weight gain. Focusing only on food intake, while ignoring energy
expenditure, minimizes the complexity of the biology of weight gain
and ultimately delays the development of truly successful
approaches.O
C 2017 The Obesity Society
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Obesity Body Weight, Energy Expenditure, and Energy Intake Church and Martin

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