Why are we (still) fat?

John C. Peters, Ph.D.

Chief Strategy Officer
Anschutz Health and Wellness Center
Professor of Medicine


2
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
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
5
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 brokenit is doing exactly
what it was designed to do

6
Put this biology into the current
environment:
Energy dense, high calorie food is everywhereand, it is
inexpensive

We no longer need to be physically active to survive

Cultural values and practices developed in a different
survival contextthey now contribute to the problem
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
U
n
h
e
a
l
t
h
y

P
r
e
f
e
r
e
n
c
e
s

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
















The Biology of Choicewe choose
for the moment

NOW
20 Years
The marketplace plays to the biology
11
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 brokenit is doing exactly
what it was designed to do



We built the environment to
serve the biology


Eat too much
Our biology applies constant
pressure to:
13
13
____________________________________
______
14
14
15
15
16
16
17
And, move too little
Leisure time physical activity has not declined

Physical activity at work has declined

Physical activity at home has declined
18
Body Weight

Energy
Intake
Our biology works best at high level of
physical activity (energy flux)
Physical Activity
Threshold for
Optimal Weight
Regulation
Unregulated Zone Regulated Zone
Adapted from Mayer et. al., 1956
Increase in physical activity
Adapted from Mayer et al, AJCN, 1956
USA Amishtoday
-603 kcal
day
-436 kcal
day
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
20
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 Producing
Jobs
Agricultural
Jobs
Church TS et al. PLoS 2011
21
1,150
1,250
1,350
1,450
1,550
1960 1970 1980 1990 2000 2010
Year
O
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(
c
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s
)
Men
Women
Daily Occupational Caloric Expenditure
Church TS, et al. (2011) PLoS One 6: e19657.
22
Trends in Housework Energy
Expenditure (1965-2005)

Archer et al. 45-year Trends in Household Management. In Press. PLOS One
4653
3553
3324
2769
2877 2806
1013
1452
1923
1977
2086
2034
0
1000
2000
3000
4000
5000
1965 1975 1985 1995 2005 2010
K
c
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Women
Men
PLOS ONE | www.plosone.org 7 February 2013 | Volume 8 | Issue 2 | e56620
Source: Ng S.W. & Popkin B.M. Obesity Reviews ( 2012). Modernization, Time Use
and Physical Activity: A shift away from movement across the globe.
0
5
10
15
20
25
30
35
40
45
0
50
100
150
200
250
1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015 2020 2025 2030
A
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Year
Active Leisure PA
Travel PA
Domestic PA
Occupational PA
Sedentary Time (hrs/wk)
1965: 235
MET-hr/wk
2009: 160
MET-hr/wk
by 2020: 142
MET-hr/wk
by 2030: 126
MET-hr/wk
US Adults Met-hours Per Week of All Physical Activity, and Hours/Week of Time in
Sedentary Behavior: Measured for 1965-2009 and Forecasted for 2010-2030

Obes Rev. 2012 August ; 13(8): 659680.
Source: Ng S.W. & Popkin B.M. Obesity Reviews (2012). Modernization, Time
Use and Physical Activity: A shift away from movement across the globe.
0
10
20
30
40
50
60
0
50
100
150
200
250
1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015 2020 2025 2030
A
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Year
Active Leisure PA
Travel PA
Domestic PA
Occupational PA
Sedentary Time (hrs/wk)
by 2030: 140
MET-hr/week
2005: 173
MET-hr/week
by 2020: 153
MET-hr/week
1961: 216
MET-hr/week
UK Adults Met-hours per Week of Physical Activity and Hours/Week of Time in
Sedentary Behavior: Measured for 1961-2005 and Forecasted for 2006-2030

Obes Rev. 2012 August ; 13(8): 659680.
0
5
10
15
20
25
30
100
150
200
250
300
350
400
450
1991 1994 1997 2000 2003 2006 2009 2012 2015 2018 2021 2024 2027 2030
A
v
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Year
Active Leisure PA
Travel PA
Domestic PA
Occupational PA
Sedentary Time (hrs/week)
by 2030: 188
MET-hr/week
2009: 213 MET-
hr/week
by 2020: 200
MET-hr/week
1991: 399
MET-hr/week
Source: Ng S.W. & Popkin B.M. Obesity Reviews (2012). Modernization, Time
Use and Physical Activity: A shift away from movement across the globe.
Chinese Adults Met-hours per Week of Physical Activity & Hours/Week of Time in
Sedentary Behavior: Measured for 1991-2009 and Forecasted for 2010-2030

Obes Rev. 2012 August ; 13(8): 659680.
Source: Ng S.W. & Popkin B.M. Obesity Reviews (2012). Modernization , Time
Use and Physical Activity: A shift away from movement across the globe.
0
5
10
15
20
25
30
35
100
150
200
250
2002 2006 2010 2014 2018 2022 2026 2030
A
v
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r
a
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h
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p
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p
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Year
Active leisure
Travel
Domestic
Occupational
Sedentary time
by 2030: 151
MET-hr/week
2008: 214
MET-hr/week
by 2020: 180
MET-hr/week
Brazilian Adults Met-hours per Week Of Physical Activity & Hours/Week Of Time
In Sedentary Behavior: Measured For 2002-2008 And Forecasted For 2009-2030

Obes Rev. 2012 August ; 13(8): 659680.
18
19
20
21
100
150
200
250
2000 2005 2010 2015 2020 2025 2030
A
v
e
r
a
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h
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p
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k

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A
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M
E
T
-
h
o
u
r
s

p
e
r

w
e
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k

Year
Active Leisure PA
Travel PA
Domestic PA
Occupational PA
Sedentary Time (hrs/week)
by 2030: 212
MET-hr/week
2005: 239
MET-hr/week
by 2020: 225
MET-hr/week
Indian Adults Met-hours per Week of Physical Activity & Hours/Week of Time in
Sedentary Behavior: Measured for 2000-2005 and Forecasted for 2006-2030

Source: Ng S.W. & Popkin B.M. Obesity Reviews (2012). Modernization , Time
Use and Physical Activity: A shift away from movement across the globe.
Obes Rev. 2012 August ; 13(8): 659680.
29
We sit too muchand, 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
Source: Lee, et.al., Lancet, 380: 2012
Inactivity and life expectancy
31
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
entertai nment
industry
heal th care
industry
transportation
system
knowledge
cost
time
convenience
safety
accessibility
situation or context
physical and social
social
trends
seasonality
home
food stores
heal th care
providers
workplace
restaurants
religious, community
and non-government
organizations
vehicle of transport
neighborhood
heal th club
parks, recreati on centers,
senior centers
community activity
providers
shopping malls
family
food stores
local government
developers
property owners
employer
school board,
districts
non-government
organizations
nonprofit
providers
community
shopping
mall
restaurants and
food outlets
recreati on
facilit ies
architecture
& building codes
government
food industry
exercise,
physical act ivit y
& sports industry
recreati on
industry
labor-saving
device
industry
information
industry
education
syst em
political advocacy/
lobbying
Secondary l everage poi nts
Pri mary leverage point s
Behavi oral setti ngs
Lifestyle
Enablers of choice
values
beliefs
life experience
social roles
educat ional
attainment
socioeconomic
status
interpersonal
relationships
life st age
habits
self identities ethnic
identities
Social
Cultural
source of
information
local school
day care
physiology
pleasure
genetics
hierarchy
of needs
Psycho-biological
Core
April 20, 2000
Nutrition Reviews, 59, 2001
The Environment and YOU
Behavior Settings
33
We need to think about the
problem in a new way
Yes, we will need new policies and
environmental interventionsbut, we still need
people to comply
What is the motivational structure that works in
the modern world?
How do healthier behaviors become part of daily
life even if they take cognitive and physical
effort?
34
We need to work WITH the
biology

Our biology is first and foremost
concerned with survival

- What are key elements of survival in the
21
st
century?



35
Survival in the 21
st
century:
Food, shelter, safety
Where do the means come from to
acquire these?

What is needed to support these
systems?
Economic growthprosperity

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

There is no compelling
reason to change
WHY?

We dont have a good enough reason to not be fat

Is focusing on health care costs the right
way to promote wellness?
(workplace example)

Most incentives for health care come via the health care
systeme.g., premiums, on-line exercises, emanate
from HR and benefitsnot day to day business conduct.
How present are these in your life daily?
Your Life
(sleep, work, family, domestic,
travel, shopping, leisure, eating,
exercise, etc.)
Health care slice of
daily life?
38
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
39
Social motivation hierarchy
Transcendence
Well Society
National defense, affordable housing,
safe neighborhoods
Collective purpose,
American Values,
National Pride
Economic health, jobs, global
competitiveness, education
40
Strategies for change
Try to structure each behavior environment?
- e.g., policies, regulations, choice architecture
Continue to focus on individual motivation?
- change must come from within
Leverage a collective motivation across society that is
consistent with todays priorities and values?
- what if healthful behavior was employment
expectation?
- plant the seeds to create demand for a healthier
environment?
41
We need to think about the
problem in a new way
We need a better reason for people to be
healthy that matters to them as individuals and
to the nation as a wholewhats in it for ME and
whats in it for US?
Work with the biologyrewards immediate and
part of daily life
Align individual and collective purpose
Align behavioral purpose and motivational
contextwork, school
Not opt ineveryone is part of itnew
behavioral expectations become part of the
woodwork
NEW THINKING
SPACE
Demand
for healthy
choices
(why?)
Opportunities
for healthy
choices
Leave
people
alone and
let them
choose
Regulate,
mandate,
tax,
control
NEW DOING SPACE
Its about
creating
demand
Catalyzing demand: Where do we start?
Schools & Home
Commerce, the Environment
Workplaces
45
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
46
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


47
We have changed our environment
more quickly than we know how to
change ourselves

Walter Lippmann (1915)

48
Thank You