Why are we fat?John C. Peters, Ph.D.

Chief Strategy OfficerAnschutz Health and Wellness Center

Professor of Medicine

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

1. agricultural policies2. air conditioning3. air pollution4. antibiotic usage at early age5. arcea nut chewing6. assortative mating7. being a single mother8. birth by C-section9. built environment10. chemical toxins11. child maltreatment12. competitive food sales in schools13. consumption of pastries and chocolate (in Burkina Faso)14. decline in occupational physical activity15. delayed prenatal care16. delayed satiety17. depression18. driving children to school19. eating away from home20. economic development21. endocrine disruptors22. entering into a romantic relationship23. epigenetic factors24. family conflict25. first-born in family26. food addiction27. food deserts28. food insecurity

29. food marketing to children30. food overproduction31. friends32. genetics33. gestational diabetes34. global food system35. grilled foods36. gut microbioata37. having children, for women38. heavy alcohol consumption39. home labor saving devices40. hunger-response to food cues41. international trade policies (globalization)42. high fructose corn syrup43. lack of family meals44. lack of nutritional education45. lack of self-control46. large portion sizes47. living in the suburbs48. living in crime-prone areas49. low levels of physical activity50. low socioeconomic status51. market economy52. marrying in later life53. maternal employment54. maternal obesity55. maternal over-nutrition during pregnancy56. maternal smoking57. meat consumption 

58. menopause59. mental disabilities60. no or short term breastfeeding61. non-parental childcare62. overeating63. participation in Supplemental Nutrition Assistance Program (formerly Food Stamp Program)64. perception of neighborhood safety65. physical disabilities66. prenatal maternal exposure to natural disasters67. poor emotional coping68. sleep deficits69. skipping breakfast70. snacking71. smoking cessation72. stair design73. stress74. sugar-sweetened beverages75. trans fats76. transportation policies77. television set in bedrooms78. television viewing79. thyroid dysfunction80. vending machines81. virus82. 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

Sedentary workplaces

Sedentary schools

Activity “unfriendly” community design

Automobiles Drive-through

conveniences Elevators/

escalators Remote controls Sedentary

entertainment Labor saving

devices Television/

computer

WEIGHT GAIN

Energy intake

Energy expenditure

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

• Humans are “energy misers”

• The biology is not broken…it is doing exactly what it was designed to do

We built the environment to serve the biology

7

__________________________________________

8

9

10

S. French J Nutr 2003

Even price has limits…

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 Amish…today

-603 kcalday

-436 kcalday

Amish Men Amish Women US Men US Women

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

9%0% 32% 35%Obesity rate

We don’t get enoughphysical 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

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

1960 1970 1980 1990 2000 2010

Year

%

Service Jobs

Goods ProducingJobs

Agricultural Jobs

Church TS et al. PLoS 2011

Daily Occupational Caloric Expenditure

1,150

1,250

1,350

1,450

1,550

1960 1970 1980 1990 2000 2010

Year

Occ

up

atio

n R

ela

ted

Da

ily E

ne

rgy

Exp

en

ditu

re (

calo

rie

s) Men

Women

-140 daily kcals

-120 daily kcals

Church TS et al. PLoS 2011

Trends in Housework Energy Expenditure (1965-2005)

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

1965 1975 1985 1995 2005 20100

1000

2000

3000

4000

5000 4653

35533324

2769 2877 2806

10131452

1923 1977 2086 2034

WomenMen

Kcal

s/w

eek

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 (%) forAll-Cause Deaths

40,842 Men & 12,943 Women, ACLS

02468

1012141618

Low CRF

Obese

Smoker

Hypertension

High Chol

Diabetes

MenWomen

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

NOW

20 Years

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 andeating behavior

entertainmentindustry

heal th careindustry

transportationsystem

knowledge

cost

time

convenience

safety

accessibility

situation or context – physical and social

social trends

seasonality

homefood stores

heal th care providers

workplace

restaurants

religious, communityand non-governmentorganizations

vehicle of transport

neighborhood

heal th club

parks, recreation centers, senior centers

community activityproviders

shopping malls

familyfood stores

local governmentdevelopers

property owners

employer

school board, districts

non-governmentorganizations

nonprofitproviders

community

shoppingmall

restaurants andfood outlets

recreationfacilit ies

architecture & building codes

government

food industryexercise,physical act ivity& sports industry

recreationindustry

labor-savingdeviceindustry

informationindustry

education system

political advocacy/lobbying

Secondary lev erage pointsPrimary leverage pointsBehavioral settingsLifesty leEnablers o f cho ice

values

beliefs

life experience

social roles

educat ionalattainment

socioeconomic status

interpersonalrelationships

life stagehabits

self identities ethnicidentities

SocialCultural

source ofinformation

local school

day care

physiology

pleasure

geneticshierarchyof needs

Psycho-bio logical Core

April 20, 20 00Nutrition Reviews, 59, 2001

The Environment and YOUBehavior Settings

The Environment and YOU: Systems

Foresight Diagram

YOU are here

What is the real problem?

Physical activity is not necessary.

We are too rich.

Food is cheap

Physical activity is not necessary

We have disposable income

AND, there is no compelling reason to change…

WHY?

Godzilla Meets Bambi

Sugar

Fat

Salt

Rest

Enjoy

Market more fresh produce

Sidewalks, brighter stairwells

Restrictions on “bad” food

Reduced health premiums

T-shirts, water bottles

…AND?

BIOLOGY

Unh

ealth

y Pr

efer

ence

s

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

Physiological

Safety and Security

Belongingness and Love

Esteem

Self-actualization

Transcendence

Need to move the focus

Social motivation hierarchy

Transcendence

Well Society

National defense, affordable housing,

safe neighborhoods

Collective purpose,

American Values, National Pride

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

Demandfor healthychoices(why?)

Opportunitiesfor healthychoices

Leave peoplealone

and let them

choose

Regulate,

mandate,

tax, control NEW “DOING” SPACE

It’s about creating demand…

Catalyzing demand: Where do we start?

Schools & Home

Commerce, the “Environment”

Workplaces

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

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 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)

ThankYou

Thank You