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