Obesity: The Big Picture

James O. Hill, Ph.D.

Anschutz Professor
University of Colorado
Anschutz Health and Wellness Center


Obesity Issues 2014
Where are we today?
Who is getting fat?
The biology of obesity
Transformational weight loss
Food vs Physical Activity
Metabolic Flexibility and Obesity
Evaluating Research
Physical activity and brain function
The new science of sedentarianism
Strategic movement through the workday
Small steps and nudges
Impact of food taxes
Role of the Food and Beverage Industry
Trends in overweight, obesity and extreme obesity, ages 20-74 years
0%
5%
10%
15%
20%
25%
30%
35%
40%
1960-62 1971-74 1976-80 1988-94 1999-00 2001-02 2003-04 2005-06 2007-08 2009-10
Overweight
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.
Extremely Obese
0%
5%
10%
15%
20%
25%
1963-65 1971-74 1976-80 1988-94 1999-00 2001-02 2003-04 2005-06 2007-08 2009-10 2011-
2012
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.
Age 12-19
Age 6-11
Age 2-5
Trends in child and adolescent overweight
Causes of Obesity
Energy intake
Energy expenditure
Energy expenditure
Energy intake
WEIGHT GAIN
Who is becoming obese?
Contributors to Obesity
Biology
Behavior
Environment

Biology: The Energy Balance System
Energy
Intake
Energy
Expenditure
Energy
Stores
Active
Regulation/Integration
Inherited
Factors
Environmental
Factors
Efficiency
Adaptive thermogenesis
Food preferences
Food environment
Physical activity
environment
Socioecological Models
Decrease
Energy
Intake
Body weight increases
Body weight does not change
Body weight decreases
Usual physical activity
Metabolic Rate
Food Intake
What happens to body weight when food intake is
decreased?
Increase
Physical
Activity
Body weight increases
Body weight does not change
Body weight decreases
Usual physical activity
Metabolic Rate
Food Intake
What happens to body weight when physical activity is
increased?
Addressing the Environment
Biology: Influenced by Environment and
Behavior
Drive to eat eat whenever food is available
Like sugar, fat, salt
Happy being sedentary little need for physical activity

Biology
Desire to Eat
Pref for sweet/fat
No Drive to be active

Food
Available
Good tasting
Energy dense
Inexpensive
Large portions
Physical Activity
Little need for physical activity in daily living
Attractiveness of sedentary Entertainment
Car for Transportation
Economics
Consume More
More for less
Greater Productivity

Decreased
Energy
Expenditure
Increased
Energy
Intake
Obesity
Sociocultural
Forces
Challenges in reducing obesity
How do we begin to study the
problem?
Foreyt, John, and Ken Goodrick. "The ultimate triumph of obesity."
The Lancet 346.8968 (1995): 134-135.
Last American becomes obese in 2230
Promoting Cognitive Skills
Making conscious efforts to overcome
biological and environment influences
toward obesity
Biology
Environment
Behavior
Hill 5-Point Plan to Reduce Obesity
Prioritize prevention over treatment
Increase physical activity of the population
Promote Smart Eating using small changes
Use small changes to change environment
Teach Cognitive Skills
Big Challenge: We have to give people a reason to want to change
Energy Gap for
prevention of weight
gain
Energy Gap for
maintenance for
weight loss
B
o
d
y

W
e
i
g
h
t

Time
What will it take to reduce obesity? The energy gap
Energy
Gap
-10% (10 kg) = 190-200 kcal/day
-15% (15kg) = 280-300 kcal/day
Energy
Gap
Obesity
How much behavior change is needed for
successful weight loss maintenance?
Example for 100 kg person
Body
Weight
Energy
Gap
Energy
Gap
Energy
Gap
Healthy Weight
Overweight
Obese
Energy Gap for Prevention of Weight Gain
(<100 kcal/day)
TRANSFORMATION
When it comes to weight, which is more important:
Food vs Physical Activity
Eat a bacon cheeseburger and consume 720 kcal in 5 min
Takes 2.6 hours of walking at moderate intensity to burn it off






I worked 8 hours today to make $500
I spent $500 in 15 min on concert tickets
When it comes to net worth, which is more important:
Income vs Spending
Body Weight

Energy
Intake
Our biology works best at high
Physical Activity
Threshold for
Optimal Weight
Regulation
Unregulated
Zone
Regulated Zone
Energy
Intake
Energy Expenditure
Smart Eating
Portion Size
Energy Density
Liquid Calories
Healthy Defaults
Messages
Eat Less and Move More
Eat Smarter and Move More
The birth of small changes
Source: D.M. Bravata et.al., JAMA 298: 2296-2304, 2007
Pedometers To Increase Activity
A better approach: Healthy Defaults
Disney parks
Kids meals come with low fat milk and fruit
Starbucks
Drinks made with low fat milk
Portion sizes/energy density
Would anyone notice a 5% reduction?
School drop offs
Buses and cars drop kids off 500 steps from
school
0
100
200
300
400
500
600
700
C
a
l
o
r
i
e
s

7-Eleven Soft Drinks
Super Big
Gulp
Gulp Big Gulp Double
Gulp
333 kcal
590 kcal
The Cheeseburger
Why Change Anything?
Program partners: Primary funder:
Developing Skills

PI: James O. Hill, Ph.D.
The 5
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Sustaining Behavior Change
Regulate
Behavior
Control/Limit
Choices
Educate to
allow people to
make better
choices
FOOD
Taxes
Pricing
Exposure
Zoning Restrictions
Menu Labeling
Portion Control
Restrictions on bad foods
Regulations for school foods
PHYSICAL ACTIVITY
Increase active transport
Reduce sedentary behavior
Improve physical activity programs
Mandate physical activity in
schools

Where is the middle ground?
Public-Private Partnerships
We will need policy but what and when?
Parents must take the
lead in reducing
childrens TV watching
and provide alternatives
Are children prey for fast
food companies?
Biology
Desire to Eat
Pref for sweet/fat
No Drive to be active

Food
Available
Good tasting
Energy dense
Inexpensive
Large portions
Physical Activity
Little need for physical activity in daily living
Attractiveness of sedentary Entertainment
Car for Transportation
Economics
Consume More
More for less
Greater Productivity

Decreased
Energy
Expenditure
Increased
Energy
Intake
Obesity
Sociocultural
Forces
Reason to push back
Different Value Equation
Social Environment of Wellness
Make better
choices
Challenges in reducing obesity
Energy Balance
Skills
Health & Wellness Center
Integration and interaction
Health &
Wellness
Clinical
Education
Research
Addressing a Complex Issue
Private
Sector
Partnerships
Community
Engagement
Create new thinking space
for creating solutions
Develop and Test
Potential Solutions
Implement
Science-Based,
Scalable Programs
and Initiatives
Model schools
Model worksites
HEALTH VS WELLNESS
Prevention Accumulating Wellness
Pulmonary GI
Dermatological
Orthopedic Genitourinary
Psychological Asthma
Diabetes
Cardiovascular Disease
Cognitive Impairment
Renal Disease
Cancer
CU Wellness Score
Diet
Quality
Quality of
Life
Sleep
Stress
Metabolic
Fitness
Physical
Fitness
Your Wellness
Score:
62 (out of 100)
Thank You!