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

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• Eat

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on

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ess ph

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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