population perspectives on obesity: etiology and intervention · population obesity: continued...

Population Perspectives on Obesity:

Etiology and Intervention

Population Perspectives on Obesity:

Etiology and InterventionRobert W. Jeffery, Ph.D.

University of MinnesotaSchool of Public Health

Division of Epidemiology

Robert W. Jeffery, Ph.D.University of MinnesotaSchool of Public Health

Division of Epidemiology

Acknowledgement of Mentors and Colleagues

Acknowledgement of Mentors and Colleagues

! Albert Bandura

! Albert Stunkard

! John Farquhar

! Henry Blackburn

! Albert Bandura

! Albert Stunkard

! John Farquhar

! Henry Blackburn

! Rena Wing

! Jean Forster

! Simone French

! Rena Wing

! Jean Forster

! Simone French

PurposesPurposes

♦ Conceptualization of population obesity.

♦ Dimensions of the current obesity epidemic and its possible causes.

♦ Research on public health approaches to obesity treatment/ prevention.

♦ Conceptualization of population obesity.

♦ Dimensions of the current obesity epidemic and its possible causes.

♦ Research on public health approaches to obesity treatment/ prevention.

Conceptualization of Individual vs Population Obesity

Conceptualization of Individual vs Population Obesity

Individual

Definition BMIHealth importance Individual riskEtiology Genetic susceptibility

Eating & exerciseIntervention Decrease susceptibility

Pharmacologic/surgicalBehavioral/education

Individual

Definition BMIHealth importance Individual riskEtiology Genetic susceptibility

Eating & exerciseIntervention Decrease susceptibility

Pharmacologic/surgicalBehavioral/education

Conceptualization of Individual vs Population Obesity: continuedConceptualization of Individual vs Population Obesity: continued

Population

Definition Prevalence

Health importance Population attributable risk

Etiology Environmental exposures Eating / exercise opportunityAffluence, Education

Intervention Change environmental exposures EducationEating / exercise opportunity / cost

Population

Definition Prevalence

Health importance Population attributable risk

Etiology Environmental exposures Eating / exercise opportunityAffluence, Education

Intervention Change environmental exposures EducationEating / exercise opportunity / cost

05

10152025

1971-74NHANES-I

1976-80NHANES-II

1988-94NHANES-III

Obesity (BMI ≥ 30) prevalence in the US, 1970-94.Obesity (BMI ≥ 30) prevalence in the US, 1970-94.

Flegal et al, 1998

Proximal Causes of Obesity Epidemic

Proximal Causes of Obesity Epidemic

! Increased eating

! Decreased physical activity

! Increased eating

! Decreased physical activity

Underlying Causes of Obesity Epidemic

Underlying Causes of Obesity Epidemic

!Changes in Environment !Changes in Environment

0

500

1000

1500

2000

1977 1987

Total energy intake per day in the US, 1977 to 1987

Total energy intake per day in the US, 1977 to 1987

Popkin et al, 2001

20

30

40

50

1980-82 1990-92 1995-97

MenWomen

Trends in leisure-time physical activity in the Minnesota Heart Survey (min/day), 1980 to 1995.

Trends in leisure-time physical activity in the Minnesota Heart Survey (min/day), 1980 to 1995.

Steffen-Batey et al, 2001

05

1015202530

1970 1980 1990 1994

Total energyTotal fatTotal CHO

From USDA, 1995

Percent change in per capita disappearance of total energy, total fat, and total CHO per day in the US, 1970-94.

Percent change in per capita disappearance of total energy, total fat, and total CHO per day in the US, 1970-94.

-250

255075

100125

1970 1980 1990 1994

BeefChickenButterCheeseFruits/VegiesSoft Drinks

Percent change in per capita disappearance of selected foods per day in the US, 1970-94.Percent change in per capita disappearance of selected foods per day in the US, 1970-94.

From USDA, 1995

| | |

Percent change in food expenditures as a proportion of income in the US, 1970-99.Percent change in food expenditures as a proportion of income in the US, 1970-99.

-40-30-20-10

0102030

1970 1980 1990 1994

At homeAwayTotal

From USDA, 1995

| | |

BMI Units* Per Fast Food Meal

.19

.54

.97

.00

.20

.40

.60

.801.001.20

Men High-incomeWomen

Low-incomeWomen

Fast Food Eating Was Positively Related to BMI in Women

Fast Food Eating Was Positively Related to BMI in Women

* 1 BMI unit equals approximately 3 kg** p < .05 Jeffery et al, 1998* 1 BMI unit equals approximately 3 kg** p < .05 Jeffery et al, 1998

**

**

Food Advertising Expenditures (millions)

Food Advertising Expenditures (millions)

Product Amount YearCoca Cola $277 1997McDonald�s $572 1998Total food industry $11,000 1997Total USDA expenditures $333 1997on nutrition education

Product Amount YearCoca Cola $277 1997McDonald�s $572 1998Total food industry $11,000 1997Total USDA expenditures $333 1997on nutrition educationAdvertising Age, 1998

012345

1970 1980 1990

Food advertising as a percent of sales averaged across 7 food types,* 1970-90.Food advertising as a percent of sales averaged across 7 food types,* 1970-90.

Almanac of Business & Industrial Financial Ratios, 1995

* Meat, dairy, canned/frozen fruit, vegetables, grain, bakery, sugar, soft drinks.

343638404244

1970 1980 1985 1990 1995

Health claim advertising ban lifted

Total Fat as a Percent of Calories in the US Food Supply 1970 to 1995

Total Fat as a Percent of Calories in the US Food Supply 1970 to 1995

From USDA, 1995

-50-40-30-20-10

01020

1970 1980 1990

CarPublicNonmotor

Percent change in means of trans-portation to work in the US, 1970-90.Percent change in means of trans-portation to work in the US, 1970-90.

US Census, 2001

| | | |

Percent change in hours of TV viewing per week, 1965-99.Percent change in hours of TV viewing per week, 1965-99.

-100-50

050

100150200250300

1965 1999French et al, 2001

TV Viewing Was Positively Related to BMI in Women

TV Viewing Was Positively Related to BMI in Women

BMI Units* Per Hour of TV Viewing

.23.40

.70

.00

.20

.40

.60

.80

Men High-incomeWomen

Low-incomeWomen

* 1 BMI unit equals approximately 3 kg** p < .05 Jeffery et al, 1998* 1 BMI unit equals approximately 3 kg** p < .05 Jeffery et al, 1998

**

**

-20

-15

-10

-5

0

1965 1975 1985 1995

Percent change in hours of house-work per week in the US, 1965-95.Percent change in hours of house-work per week in the US, 1965-95.

Bianchi et al, 2000

| | | | |

Percent change in total hours worked for pay per week among married couples the US, 1970-97.

Percent change in total hours worked for pay per week among married couples the US, 1970-97.

Jacobs & Gerson, 2001

05

10152025

1970 1997

What Can Be Done About the Obesity Epidemic?

What Can Be Done About the Obesity Epidemic?

!Better education about eating and exercise.

!Reduce environmental exposures that promote overeating and under-exercising.

!Better education about eating and exercise.

!Reduce environmental exposures that promote overeating and under-exercising.

The Healthy Worker Project (HWP)

The Healthy Worker Project (HWP)

A randomized trial of worksite interventions

for weight loss.

A randomized trial of worksite interventions

for weight loss.

Jeffery et al, 1993

HWP Project OverviewHWP Project Overview! Thirty-two (32) worksites employing

approximately 20,000 people.

! Randomized to treatment or control

! Two years of intervention on weight

! Evaluation via cohort and cross-sectional surveys

! Thirty-two (32) worksites employing approximately 20,000 people.

! Randomized to treatment or control

! Two years of intervention on weight

! Evaluation via cohort and cross-sectional surveys

Jeffery et al, 1993

HWP InterventionHWP Intervention! 4 rounds! 6 months duration! No entry restrictions! Self-selected goals! Self-help manual! Biweekly group instruction! Payroll-based incentive system

! 4 rounds! 6 months duration! No entry restrictions! Self-selected goals! Self-help manual! Biweekly group instruction! Payroll-based incentive systemJeffery et al, 1993

Participation and Short-term Weight Loss

Participation and Short-term Weight Loss

Participants 2041

% of all overweight employees 38.3

Mean weight loss (lb) 4.8

Participants 2041

% of all overweight employees 38.3

Mean weight loss (lb) 4.8

Jeffery et al, 1993

HWP: Mean change in BMI over 2 years.HWP: Mean change in BMI over 2 years.

* Controlling for age, sex, and education.Jeffery et al, 1993

* Controlling for age, sex, and education.Jeffery et al, 1993

-0.10-0.08-0.06-0.04-0.020.000.020.040.060.080.10

Baseline Follow-up

TreatmentControl

Minnesota Heart Health Program (MHHP)

Minnesota Heart Health Program (MHHP)

A 10-year research and demonstration project to evaluate the effectiveness of multicomponent interventions to reduce CVD incidence and mortality

A 10-year research and demonstration project to evaluate the effectiveness of multicomponent interventions to reduce CVD incidence and mortality

Luepker et al, 1994

Description of MHHPDescription of MHHP! Three matched community pairs

! Seven years of intervention including:" risk factor screening" mass media" adult education" worksite intervention" school intervention" restaurant intervention" etc.

! Three matched community pairs

! Seven years of intervention including:" risk factor screening" mass media" adult education" worksite intervention" school intervention" restaurant intervention" etc.

Luepker et al, 1994

25.0025.2525.5025.7526.0026.2526.5026.7527.00

-3 -2 -1 0 1 2 3 4 5 6 7

ComparisonEducation

25.0025.2525.5025.7526.0026.2526.5026.7527.00

-3 -2 -1 0 1 2 3 4 5 6 7

ComparisonEducation

Mean BMI in MHHP Education and Comparison Communities by Year: Cross-sectional SurveysMean BMI in MHHP Education and Comparison Communities by Year: Cross-sectional Surveys

BM

IB

M I

B(3) B(2) B(1) B0 E1 E2 E3 E4 E5 E6 E7B(3) B(2) B(1) B0 E1 E2 E3 E4 E5 E6 E7

B and E YearsB and E YearsJeffery et al, 1995

Pound of Prevention (POP)

Pound of Prevention (POP)

Randomized trial evaluating the effectiveness of a low cost

educational approach in reducing the rate of weight gain with age

Randomized trial evaluating the effectiveness of a low cost

educational approach in reducing the rate of weight gain with age

Jeffery et al, 1999

POP Study ParticipantsPOP Study Participants! General recruitment through mass

media (228 men, 594 women)

! Special recruitment of 400 low income women through WIC

! Eligibility requirements:" Age 20 to 45 years" Not pregnant in the last year" No serious health conditions

! General recruitment through mass media (228 men, 594 women)

! Special recruitment of 400 low income women through WIC

! Eligibility requirements:" Age 20 to 45 years" Not pregnant in the last year" No serious health conditions

Jeffery et al, 1999

TreatmentsTreatments# Control: No contact

# Education: Monthly newsletters emphasizing 5 themes: 1. Weigh yourself regularly

2. Eat 2 fruits/day3. Eat 3 vegetables/day4. Reduce fat intake5. Increase exercise/walking

Additional education offerings 2 times per year (e.g., classes, contests, correspondence course)

# Education + Incentive: Education program (above) + lottery drawing monthly to encourage newsletter reading.

# Control: No contact

# Education: Monthly newsletters emphasizing 5 themes: 1. Weigh yourself regularly

2. Eat 2 fruits/day3. Eat 3 vegetables/day4. Reduce fat intake5. Increase exercise/walking

Additional education offerings 2 times per year (e.g., classes, contests, correspondence course)

# Education + Incentive: Education program (above) + lottery drawing monthly to encourage newsletter reading.

Jeffery et al, 1995

Weight change (lb) by treatment group by year.Weight change (lb) by treatment group by year.

012345

Baseline Year 1 Year 2 Year 3

ControlNewsletterNewsletter + Incentive

012345

Baseline Year 1 Year 2 Year 3

ControlNewsletterNewsletter + Incentive

Adjusted means, controlling for age, sex, type, education, and ∆ smoking. Jeffery et al, 1999Adjusted means, controlling for age, sex, type, education, and ∆ smoking. Jeffery et al, 1999

Cafeteria Study of Price and Availability Influences on

Fruit and Salad Consumption

Cafeteria Study of Price and Availability Influences on

Fruit and Salad Consumption

! Three (3) weeks baseline observation! Three (3) weeks interventions

" 50% price reduction" increased choices

! Three (3) weeks return to baseline

! Three (3) weeks baseline observation! Three (3) weeks interventions

" 50% price reduction" increased choices

! Three (3) weeks return to baselineJeffery et al, 1994

0

10

20

30

40

50

0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 450

10

20

30

40

50

0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45

DayDay

BaselineBaseline InterventionIntervention Follow-upFollow-up

X = 11X = 11 X = 31X = 31 X = 14X = 14Num

ber o

f Fru

it Pu

rcha

ses

Num

ber o

f Fru

it Pu

rcha

ses

Jeffery et al, 1994

0

10

20

30

40

50

0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 450

10

20

30

40

50

0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45

DayDay

Poun

ds o

f Sal

ad

Purc

hase

dPo

unds

of S

alad

Pu

rcha

sed

BaselineBaseline InterventionIntervention Follow-upFollow-up

X = 8X = 8 X = 24X = 24 X = 12X = 12

Jeffery et al, 1994

020406080

100

Average School 1urban

School 2Suburban

Baseline 1Low priceBaseline 2

Fruit Sales as a Function of PriceFruit Sales as a Function of Price

Average vs each schoolFrench et al, 1997

Average vs each schoolFrench et al, 1997

Mea

n w

eekl

y fr

uit s

ales

020406080

100120140160

Average School 1urban

School 2suburgan

Baseline 1Low priceBaseline 2

Carrot Sales as a Function of PriceCarrot Sales as a Function of Price

Average vs each school

French et al, 1997Average vs each school

French et al, 1997

Mea

n w

eekl

y ca

rrot

sal

es

01020304050

%

Sameprice

50% low-fat

discount

Sameprice

01020304050

%

Sameprice

50% low-fat

discount

Sameprice

Low-Fat Snack Sales in Vending Machines (%) as a Function of Price

Low-Fat Snack Sales in Vending Machines (%) as a Function of Price

French et al, 1997French et al, 1997

CHIPSCHIPS! Randomized trial with Latin Squares design

studying effects of price and health education on vending machine snack choices.

! 12 worksites and 12 high schools! Health education:

" None" Fat color codes" Fat color codes + promotional ads

! Pricing:" Equal" Low-fat discount of 10%, 25%, 50%

! Randomized trial with Latin Squares design studying effects of price and health education on vending machine snack choices.

! 12 worksites and 12 high schools! Health education:

" None" Fat color codes" Fat color codes + promotional ads

! Pricing:" Equal" Low-fat discount of 10%, 25%, 50%


05

10152025

Equal -Ź10% -Ź25% -Ź50%05

10152025

Equal -Ź10% -Ź25% -Ź50%% S

ales

LF

Snac

ks%

Sal

es L

F Sn

acks

PricePrice% Increase in sales: 9% 39% 93%% Increase in sales: 9% 39% 93%

Effect of Price on Low-Fat Snack SalesEffect of Price on Low-Fat Snack Sales


0

5

10

15

20

25

No Label Label Label & Sign0

5

10

15

20

25

No Label Label Label & SignPromotionPromotion

% S

ales

LF

Snac

ks%

Sal

es L

F Sn

acks

Effect of Health Promotion on Low-Fat Snack Sales

Effect of Health Promotion on Low-Fat Snack Sales

% Increase in sales: 1% 8%% Increase in sales: 1% 8%


1. University employees given membership to a campus recreation facility did not use it more than employees not given memberships.

2. Only 2 of 616 participants in a weight gain prevention study used free access to a community YWCA that included exercise facilities and free child care.

1. University employees given membership to a campus recreation facility did not use it more than employees not given memberships.

2. Only 2 of 616 participants in a weight gain prevention study used free access to a community YWCA that included exercise facilities and free child care.

Results of Two Studies on the Effects of Price on the Use of Exercise Facilities

Results of Two Studies on the Effects of Price on the Use of Exercise Facilities

French, et alFrench, et al

Sherwood, et alSherwood, et al

13.8c15.5b

12.7a

11.1a

0

5

10

15

20

NoIntervention

Signs Signs +Music +Artwork

NoIntervention%

Peo

p le

Usi

ng th

e S t

air s

Percentage of People Using the Stairs During Each Phase of the Study

Percentage of People Using the Stairs During Each Phase of the Study

NOTE: Percentages with unshared superscripts differ significantly, p < .05.

Boutelle et al, 2002

NOTE: Percentages with unshared superscripts differ significantly, p < .05.

Boutelle et al, 2002

Policy Implications of an Environmental Perspective on Obesity

Policy Implications of an Environmental Perspective on Obesity

1. Reduce food availability� Number of outlets� Hours of operation� Portion sizes

2. Increase food price� All food� Energy-dense food

3. Limit food promotion

1. Reduce food availability� Number of outlets� Hours of operation� Portion sizes

2. Increase food price� All food� Energy-dense food

3. Limit food promotion

Public Opinion on Who Is Responsible for Today�s Diet-Related Problems

(n = 821)

Public Opinion on Who Is Responsible for Today�s Diet-Related Problems

(n = 821)

! Individuals 80%

! Stores 2%

! Manufacturers 14%

! Individuals 80%

! Stores 2%

! Manufacturers 14%

Jeffery et al, 1990

Public Opinion of 8 Specific Public Policy Measures Related to Food

Public Opinion of 8 Specific Public Policy Measures Related to Food

Positive Neutral Negative

1. Limit food advertising on children�s TV X

2. Require schools to serve low-fat food X

3. Ban high-fat food from school vending machines X

4. Warning labels on high-fat food X


1. Limit food advertising on children�s TV X

2. Require schools to serve low-fat food X

3. Ban high-fat food from school vending machines X

4. Warning labels on high-fat food X

Jeffery et al, 1990

Public Opinion of 8 Specific Public Policy Measures Related to Food: continuedPublic Opinion of 8 Specific Public Policy Measures Related to Food: continued


5. Tax incentives for restau-rants to serve low-fat food. X

6. Tax incentives for farmers to produce lower fat meat and dairy products. X

7. Tax high-fat food. X

8. Restrict high-fat food salesto minors. X


5. Tax incentives for restau-rants to serve low-fat food. X

6. Tax incentives for farmers to produce lower fat meat and dairy products. X

7. Tax high-fat food. X

8. Restrict high-fat food salesto minors. X

Jeffery et al, 1990

Current Research DirectionsCurrent Research Directions

♦ Further examine environmental correlates of obesity

♦ Expand environmental change research to include new exposures and body weight outcomes

♦ Further examine environmental correlates of obesity

♦ Expand environmental change research to include new exposures and body weight outcomes

population perspectives on obesity: etiology and intervention · population obesity: continued...

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