We must develop a better understanding of energy balance, if we hope to manage the obesity epidemic.
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Transcript of We must develop a better understanding of energy balance, if we hope to manage the obesity epidemic.
We must develop a better understanding of energy balance, if
we hope to manage the obesity epidemic
Stunkard Lifetime Achievement Awards
2012 – John G. Kral, MD, PhD, FACS
2011 – Barry M. Popkin, PhD
2010 – Van Saxton Hubbard, MD, PhD
2009 – George L. Blackburn, MD, PhD
2008 – Constantine Londos, PhD
2007 – Lars Sjöström, MD, PhD
2006 – Jules Hirsch, MD
2005 – Theodore Van Itallie, MD
2004 – Claude Bouchard, PhD
2003 – George A. Bray, MD
2002 – Elliot Danforth, Jr., MD
2001 – Mario DiGirolamo, MD
2000 – F. Xavier Pi-Sunyer, MD
Greg Hand, Jim Hill, Ed Archer, andRobin Shook
Thanks to colleagues for slides and comments about
this lecture
Outline • Obesity is a world-wide epidemic• Causes are very complex
• Environmental changes• Occupation• Household• Transport
• Personal habits• Dietary intake• Physical activity
• Fitness and Fatness• Strategies for addressing the obesity epidemic
Obesity is a world-wide epidemic
Does anyone here need to see the changing maps?
Outline • Obesity is a world-wide epidemic• Causes are very complex
• Environmental changes• Occupation• Household• Transport
• Personal habits• Dietary intake• Physical activity
• Fitness and Fatness• Strategies for addressing the obesity epidemic
Energy Balance
Calories Consumed Calories Burned
Energy Balance- simple model
Slide courtesy ofRobin Shook
Next slide is courtesy of Claude BouchardEnergy Balance – Complex Model
Physical EnvironmentUrban sprawl
Population density
Absence of sidewalks
Building design
Automobile dependence
Pollutants
Genetic hypotheses
Biology
Viruses RMR
Regulators of adipogenesis: RAR, RXR, PPAR, C/EBP,
SREBP-1c, PGC-1, etc.
ThermogenesisLipid ox
Peripheral regulators of appetite: PYY, insulin, leptin,
ghrelin, CCK, GLP-1, etc.
CNS regulators of appetite: NPY, -MSH, CART, Orexins, Agouti,
MC4R, MCH, AGRP, etc.
n-6/n-3 PUFAs
So
cial
En
viro
nm
ent
• Few
er
mea
ls a
t h
om
e
• Eat
ing
o
n t
he
run
• So
ciet
y o
f sp
ecta
tors
in
stea
d o
f p
arti
cip
ant
• Po
wer
ful
and
co
nst
ant
adve
rtis
ing
• Pre
ssu
re
to b
e se
den
tary
• Eat
ing
as
recr
eati
on
• Pre
ssu
re
to c
on
sum
e
Beh
avior
Larg
er p
ortio
ns
Co
rn fru
ctose syru
p
Calo
rie-d
ense
foo
ds
Mo
re seden
tarismL
ess ph
ysical activity
Sm
okin
g
ces
sa
tion
Certain
m
edicatio
ns
Lactatio
nH
igh
fat
diets
Matern
al-fetal
nu
trition
Epigenetics
Obesity
Adipogenesis
Overweight
Genetic Predisposition
Energy Expenditure
Energy Intake Nutrient / Energy
Partitioning
Cooke D; Nature Reviews Drug Discovery 5, 919-931 Slide courtesy of Jim Hill
Energy Balance System
Obesity Epidemic Caused by Eating too Much, Claims Academic
Average caloric expenditure in 1980»Women=950 kcal/day»Men=1380 kcal/day
Average caloric intake is now 3,500 kcal/day
“Over the past 25 years…there has been no change in our levels of physical activity” “there has been no change in energy expenditure”Article on British Science Festival in the September 16, 2010 Daily Telegraph
Outline • Obesity is a world-wide epidemic• Causes are very complex
• Environmental changes• Occupation• Household• Transport
• Personal habits• Dietary intake• Physical activity
• Fitness and Fatness• Strategies for addressing the obesity epidemic
Jobs in U.S. Over Last 50 Years
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
Church TS et al. PLOS ONE 2011;6(5): e19657
Occupational EE and Obesity
Household Management Energy Expenditure/Week
Archer E, et al. (2013) PLoS ONE 8(2): e56620. doi:10.1371/journal.pone.0056620
Occupational and Domestic PA trends in Chinese Adults, 1991-2000
Monda et al. Eur J Clin Nutr. 2008; 62: 1316-1325
Transport
Slide courtesy of Ed Archer
Brownson, R. C., Boehmer, T. K., & Luke, D. A. (2005). Declining rates of physical activity in the United States: what are the contributors? Annual Review of Public Health, 26, 421-443. doi: 10.1146/annurev.publhealth.26.021304.144437Slide courtesy of Robin Shook
We Must Carefully Evaluate and Consider both Energy Intake
and Energy Expenditure
Outline • Obesity is a world-wide epidemic• Causes are very complex
• Environmental changes• Occupation• Household• Transport
• Personal habits• Dietary intake• Physical activity
• Fitness and Fatness• Strategies for addressing the obesity epidemic
Cause(s) of the Obesity Epidemic
Increases in energy intake?
Decreases in energy expenditure?
Combination of increases in intake and decreases in expenditure?
»50/50?
»30/70?
»70/30?
Validity of NHANES Dietary Data
Reported Energy Intake (rEI) ÷ Basal Metabolic Rate (BMR)
rEI/BMR:
<1.35 or >2.40 = Implausible
Expected value ~1.55
Archer E, Hand GA, Blair SN (2013) PLoS ONE 8(10): 76632.doi:10.1371/journal.pone.0076632Slide courtesy of Ed Archer
The Mean rEI/BMR Values
Men: 1.31
Women: 1.19
Obese Men: 1.21
Obese Women: 1.10»This value is the equivalent of a
comatose patient with an IV drip
Archer E, Hand GA, Blair SN (2013) PLoS ONE 8(10): 76632.doi:10.1371/journal.pone.0076632Slide courtesy of Ed Archer
Archer E, Hand GA, Blair SN (2013) PLoS ONE 8(10): e76632. doi:10.1371/journal.pone.0076632
Slide courtesy of Ed Archer
Energy Balance
Obesity
Body Weight
Energy Intake
Our biology works best at high level of physical activity
Physical Activity Threshold for Optimal Weight Regulation
“Unregulated” Zone “Regulated” Zone
Adapted from Mayer et. al., 1956Slide courtesy of Jim Hill
Increase in physical activity
If energy balance is achieved more easily at a high energy flux, then people who
maintain constant stores are more likely:
• to be in a higher state of energy flux.
• to maintain a higher activity energy expenditure.
• to have a higher energy expenditure at rest (higher RMR).
• to have minimal body composition change.
Slide courtesy of Gregory Hand
Energy Balance Study
2-year Observational study (6 month data competed), measurements done quarterly
Healthy women and men; age 21-35; BMI 20-35
Measurements at baseline, 3 month, 6 month
ΔEnergy stores: DXA; caloric value of lean and adipose tissue changes based on Hall model.
Energy expenditure(EE): average of 10-day wear periods of Body Media’s SenseWear armband device.
Doubly labeled water EE measurements on 200 participants 12 months
Energy intake: calculated as ΔEs + Ee
Thanks to Dan O’Connor and Tony Jackson for calculating change in energy stores using Kevin Hall’s model (AJCN 88: 1495-1503, 2008).
Slide courtesy of Gregory Hand
Total Daily Energy Expenditure and Energy Intake Highest in the Energy Balanced Group.
Energy intake was calculated as energy expenditure + change in energy stores. Thanks to Dan O’Connor and Tony Jackson for calculating change in energy stores using Kevin Hall’s model (AJCN 88: 1495-1503, 2008. Slide courtesy of Gregory Hand
Kcals/kg/day
33
34
35
36
37
38
39
TDEI TDEE
(-) Energy Balance Energy Balance (+) Energy Balance
Significant differences were found between intake and expenditure in the negative and positive groups.
Energy Balance group higher expenditure than (-) EB group and higher intake than (+) EB group.
Change in RMR by quintile of Energy Balance
RM
R (m
l/kg/min) 2.4
2.6
2.8
3.0
3.2
Negative BalanceBalancedPositive Balance
Baseline Month 6
88±17 Kcals/day
26±36 Kcals/day
-182±21 Kcals/day
Change Per Day
Reduced RMRcompletely negates the caloric intake deficit for (-) EBGroup.
Slide courtesy of Gregory Hand
Outline • Obesity is a world-wide epidemic• Causes are very complex
• Environmental changes• Occupation• Household• Transport
• Personal habits• Dietary intake• Physical activity
• Fitness and Fatness• Strategies for addressing the obesity epidemic
Every week in some of the world’s best medical/scientific journals there are articles on obesity and some health outcome, but physical activity or fitness is not mentioned in the article
Joint Associations of CRF and % Body Fat with All-cause Mortality, ACLS Adults 60+
0
10
20
30
40
Fit Unfit
Normal
Obese
Death rate/1,000 person-years
Rates adjusted for age, sex and exam year
Deaths 151 190 29 72
Sui M et al. JAMA 2007; 298:2507-16
Adiposity measures as predictors of long-term physical disability. Ann Epidemiol 2012; 22:710-16
Melbourne Collaborative Cohort Study of 7,142 women and menAfter 14 year follow-up, participants “were asked about difficulties performing certain activities because of their health. Activities included bathing, dressing, eating, getting out of a chair or bed, going to our using the toilet at home, and walking about 200-300 meters”.Physical activity or fitness was not assessed and taken into account in the analyses.
Disability and quintiles of adiposity. Men (A) and Women (B)
Outline • Obesity is a world-wide epidemic• Causes are very complex
• Environmental changes• Occupation• Household• Transport
• Personal habits• Dietary intake• Physical activity
• Fitness and Fatness• Strategies for addressing the obesity epidemic
How Should We Deal with the Obesity Epidemic?
Understand energy balance
Design interventions to address the problem»Public policy»Educational programs»Clinical medicine»Technological lifestyle interventions
Conduct research to test interventions
Implement successful interventions
More Support for Physical Activity Research
NIH Estimates of Funding for Nutrition and Food Categories
Dollars in millions and rounded
Categories FY 2013 FY 2008-13
Anorexia $11 $61
Digestive diseases $1,704 $10,199
Eating disorders $27 $144
Food allergies $33 $99
Food safety $287 $1,728
Nutrition $1,386 $8,825
Obesity $827 $4,983
Total $4,275 $26,039
http://report.nih.gov/categorical_spending.aspx
NIH Estimates of Funding for Physical Activity and Exercise
http://report.nih.gov/categorical_spending.aspx
Out of 233 categories of funding that are listed on the website
Number of categories of exercise, physical activity, or physical fitness
Zero!!!!!!
Summary
My primary hopes for the future:•There will be more emphasis on both sides of the energy balance equation when trying to determine the causes of the obesity epidemic•All peer-reviewed studies on health outcomes will measure both adiposity/fat distribution and physical activity/fitness accurately and take both into account in the analyses•There will be more balance in research funding for physical activity and obesity
ENERGY BALANCE Staff and Consultants
Principal Investigators»Steve Blair»Gregory Hand»James Hebert
Consultants/Advisors» David Allison» John Blundell » Timothy Church» James Hill» Marc Hamilton » Tony Jackson » John Jakicic» Peter Katzmarzyk » Dan O’Connor» Diana Thomas » Gregory Welk
Funded by an unrestricted researchgrant from The Coca-Cola Company.
Senior StaffStephanie BurgessPatrick CrowleyMadisson DeMelloTom HurleyBrent HuttoJason JaggersAmanda PaluchReena PatelSarah SchumacherRobin ShookXuemei Sui