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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
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 schools Activity “unfriendly”
Elevators/escalators Remote controls Sedentary
Labor saving devices Television/computer
Obesity: Evolutionary Biology, the Environment, Society and You
The Take Away…
• Why we are the way we are…survival
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 cognition—individual 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 broken…it is doing exactly what it was designed to do
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
-603 kcal day
-436 kcal day
35% US Women
Amish Men Amish Women US Men
From Bassett et.al., Med. And Sci. in Sports and Exer., 2004
We don’t 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
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)
-140 daily kcals
-120 daily kcals
1960 1970 1980 1990 2000 2010
Church TS et al. PLoS 2011
Trends in Housework Energy Expenditure (1965-2005)
2769 2877 2806
1923 1977 2086 2034
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, it’s 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
Hy pe r
te ns io n
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 Choice…we choose for the moment
The marketplace plays to the biology
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
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
hierarchy of needs
life experience socioeconomic status knowledge local school neighborhood day care
April 20, 20 00
Nutrition Reviews, 59, 2001
The Environment and YOU: Systems
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
Market more fresh produce
Sidewalks, brighter stairwells
Restrictions on “bad” food Reduced health premiums
Salt Rest Enjoy
T-shirts, water bottles
Drive motivation for behavior change by linking desired behaviors to meeting basic needs
Need to move the focus
Self-actualization Esteem Belongingness and Love
Safety and Security
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 today’s 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
It’s about creating demand…
Catalyzing demand: Where do we start?
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) • Nudge—choice 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 citizen—as a way to build demand
• 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 economy…the ―prosperity engine‖. • There is no ―win-win‖ business model for healthy behaviors…yet
“We have changed our environment more quickly than we know how to change ourselves”
Walter Lippmann (1915)
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