Obesity – It’s More Obesity – It’s More than Just Caloriesthan Just Calories

Kristie J. Lancaster, PhD, RDKristie J. Lancaster, PhD, RD

New York UniversityNew York University

June 29, 2012June 29, 2012

ObjectivesObjectives

Definition of ObesityDefinition of Obesity Prevalence of Obesity in the U.S.Prevalence of Obesity in the U.S. Consequences of ObesityConsequences of Obesity Factors Influencing ObesityFactors Influencing Obesity

What is Obesity?What is Obesity?

Body weight in relation to heightBody weight in relation to height Measured through:Measured through:

– Body Mass Index (BMI)Body Mass Index (BMI)– Waist CircumferenceWaist Circumference

What is Obesity?What is Obesity?

BMI (kg/mBMI (kg/m22))

UnderweightUnderweight < 18.5 < 18.5

Normal weightNormal weight 18.5 - 24.9 18.5 - 24.9

OverweightOverweight 25 - 29.9 25 - 29.9

ObesityObesity 30 + 30 +

Adapted fromAdapted from Clinical Guidelines on the Identification, Evaluation, and Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults, 1998Treatment of Overweight and Obesity in Adults, 1998

2000

Obesity Trends* Among U.S. AdultsBRFSS, 1990, 2000, 2010

(*BMI 30, or about 30 lbs. overweight for 5’4” person)

2010

1990

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Age-Adjusted Prevalence of Age-Adjusted Prevalence of Obesity (BMIObesity (BMI30) in Men 1988-30) in Men 1988-20102010

0

10

20

30

40

50

60

70

1988-1994 1999-2000 2001-2002 2003-2004 2005-2006 2007-2008 2009-2010

White Men Black Men Mexican American Men

Flegal et al., 2010 & 2012

Age-Adjusted Prevalence of Age-Adjusted Prevalence of Obesity (BMIObesity (BMI30) in Women 1960-30) in Women 1960-20102010

0

10

20

30

40

50

60

70

1960-62 1971-74 1976-80(82-84)

1988-94 1999-2000

2001-2002

2003-2004

2005-2006

2007-2008

2009-2010

White Women Black Women Mexican American Women

Source: CDC 1999; Flegal et al., 2012

Age-Adjusted Prevalence of Age-Adjusted Prevalence of Obesity in Boys 6-11y 1976-2010Obesity in Boys 6-11y 1976-2010

0

10

20

30

40

50

60

70

1976-1980 1988-1994 1999-2002 2003-2006 2007-2010

White Black Mexican American

Health US 2011

Age-Adjusted Prevalence of Age-Adjusted Prevalence of Obesity in Boys 12-19y 1976-2010Obesity in Boys 12-19y 1976-2010

0

10

20

30

40

50

60

70

1976-1980 1988-1994 1999-2002 2003-2006 2007-2010

White Black Mexican American

Health US 2011

Age-Adjusted Prevalence of Age-Adjusted Prevalence of Obesity in Girls 6-11y 1976-2010Obesity in Girls 6-11y 1976-2010

0

10

20

30

40

50

60

70

1976-1980 1988-1994 1999-2002 2003-2006 2007-2010

White Black Mexican American

Health US 2011

Age-Adjusted Prevalence of Age-Adjusted Prevalence of Obesity in Girls 12-19y 1976-2010Obesity in Girls 12-19y 1976-2010

0

10

20

30

40

50

60

70

1976-1980 1988-1994 1999-2002 2003-2006 2007-2010

White Black Mexican American

Health US 2011

OBESITYCertain Cancers

Osteoarthritis

Stroke

Sleep Apnea

Diabetes

High Blood pressure

Paying the Costs of Paying the Costs of ObesityObesity The annual estimated cost of obesity The annual estimated cost of obesity

in the U.S. is $190 billionin the U.S. is $190 billion– 20.6% of health care spending in the U.S.20.6% of health care spending in the U.S.

Childhood obesity costs $14.1 billion in Childhood obesity costs $14.1 billion in direct medical costsdirect medical costs

Reducing diabetes and hypertension Reducing diabetes and hypertension by 5% would save $9 billion a yearby 5% would save $9 billion a year

Costs to employers: absenteeism, Costs to employers: absenteeism, disability, years of life lostdisability, years of life lost

Being a Healthy Being a Healthy WeightWeight Easier to move Easier to move Easier to breatheEasier to breathe More energyMore energy Decreases disease riskDecreases disease risk

– Even losing 10 lbs can help lower Even losing 10 lbs can help lower blood pressure and reduce or blood pressure and reduce or prevent hypertensionprevent hypertension

It’s a Matter of Energy It’s a Matter of Energy Balance Balance

Weight Gain:Weight Gain:Calories In Calories In >> Calories Out Calories Out

Weight Loss:Weight Loss:Calories In Calories In < < Calories OutCalories Out

No Weight Change:No Weight Change:Calories In Calories In = = Calories OutCalories Out

Change Diet & Increase Physical Activity

Simple. Right?: Simple. Right?:

%OBESE

ORUNDERWT

PublicTransport

PublicSafety

HealthCare

Sanitation

Agricultural/Gardens/

Local markets

Manufactured/Imported

Food

Labor

LeisureActivity

Facilities

Infections

WorksiteFood &

Activities

Family& Home

SchoolFood &Activity

Globalizationof markets

Development

Media

EnergyExpenditure

FoodIntake:NutrientDensity

INTERNATIONALFACTORS

NATIONAL/REGIONAL

COMMUNITYLOCALITY

WORK/SCHOOL/HOME

Food &Nutrition

Education

Media &Culture

Social Sec.

Health

Urbanization

Transport

INDIVIDUAL POPULATION

NationalPerspective Kumanyika et al.

What Drives the Foods What Drives the Foods We Choose?We Choose?

34%

31%

35%

26%

53%

43%

26%

26%

Some Impact Great Impact

Taste

IFIC Food & Health Survey 2009

Price

Healthfulness

Convenience

87%

74%

61%

52%

What Makes it Harder to What Makes it Harder to Change Diet?Change Diet?

Increasing CaloriesIncreasing Calories Culture/EthnicityCulture/Ethnicity Socioeconomic StatusSocioeconomic Status Food MarketingFood Marketing Food EnvironmentFood Environment

All foods once looked like All foods once looked like this...this...

...but now many foods look like ...but now many foods look like this.this.

INCREASING CALORIESINCREASING CALORIES

Dietary Intake Has Dietary Intake Has IncreasedIncreased

Adults are eating more:Adults are eating more: Soft drinksSoft drinks Fruit drinksFruit drinks Hamburgers & Hamburgers &

cheeseburgerscheeseburgers Mexican fast foodMexican fast food

Youth are eating more:Youth are eating more: Soft drinksSoft drinks Fruit drinksFruit drinks Hamburgers & Hamburgers &

cheeseburgerscheeseburgers PizzaPizza Mexican fast foodMexican fast food

140 calories 3-inch diameter

210 more calories!

350 calories 6-inch diameter

Increasing PortionsIncreasing Portions

20 Years Ago Today20 Years Ago Today

When we’re served more, we eat more

610 calories6.9 ounces

Calorie difference: 400 calories

FRENCH FRIESFRENCH FRIES 20 Years Ago Today

210 calories

2.4 ounces

COFFEE COFFEE 20 Years Ago

Coffee(with whole milk and sugar)

Today

Mocha Coffee(with steamed whole milk

and mocha syrup)

45 calories 8 ounces

350 calories16 ounces

Calorie difference: 305 calories

Calorie difference: 165 calories

250 calories 20 ounces

85 calories 6.5 ounces

SODASODA20 Years Ago Today

Bigger Bottles, Bigger Bigger Bottles, Bigger ConsumptionConsumption

Contribution of All Contribution of All Beverages to Overall Beverages to Overall Energy IntakeEnergy Intake

1214

1921

0

5

10

15

20

25

Per

cen

tag

e

1965 1977 1989 2002

Duffey & Popkin, 2007

Per Capita Energy Per Capita Energy IntakeIntake

0

20

40

60

80

100

120

140

160

180

200

1965 1977 1988 2002

Coffee & Tea Low-fat Milk Fruit Juices Alcohol

Soda Fruit Drinks Total SSB Duffey & Popkin, 2007

SSB & Weight & SSB & Weight & Related DiseasesRelated Diseases

Higher intake of calories from SSB Higher intake of calories from SSB higher increase in waist higher increase in waist circumference in children and youth, circumference in children and youth, and higher BMI percentile in youthand higher BMI percentile in youth

Higher SSB intake Higher SSB intake higher risk of higher risk of diabetesdiabetes

Higher SSB intake is associated with Higher SSB intake is associated with higher cholesterol levels and higher cholesterol levels and coronary heart diseasecoronary heart disease

Increase in Eating OutIncrease in Eating Out

People eat out more oftenPeople eat out more often– In 2010, almost half of all money spent on In 2010, almost half of all money spent on

food was for food eaten away from homefood was for food eaten away from home Eating out is associated with higher Eating out is associated with higher

energy intake energy intake Higher fast food consumption …Higher fast food consumption …

– higher energy, total fat, saturated fat, and higher energy, total fat, saturated fat, and cholesterol intakecholesterol intake

– lower intake of nutrients including vitamins lower intake of nutrients including vitamins A and C, calciumA and C, calcium

DISPARITIES IN OBESITYDISPARITIES IN OBESITY

Health DisparitiesHealth Disparities

Differences in prevalence of diseases, Differences in prevalence of diseases, health outcomes, and/or access to health outcomes, and/or access to healthcare across healthcare across racial, ethnic or racial, ethnic or socioeconomic groupssocioeconomic groups

Obesity Prevalence by Obesity Prevalence by EthnicityEthnicity

Whites Blacks

Latinos

Age-Adjusted Prevalence of Age-Adjusted Prevalence of Diagnosed Diabetes by Diagnosed Diabetes by Race/Ethnicity and SexRace/Ethnicity and Sex

CDC

3838

Factors that Influence the Factors that Influence the Health of Communities of Health of Communities of Color Color Internal Factors: Internal Factors:

– Cultural Beliefs and Values Cultural Beliefs and Values Behavioral Practices and Social Norms (e.g. diet, Behavioral Practices and Social Norms (e.g. diet,

smoking, physical activity, body image)smoking, physical activity, body image)

– Psychosocial FactorsPsychosocial Factors– GeneticsGenetics

External Factors:External Factors:– Economic DisadvantageEconomic Disadvantage– Physical and Policy Environments Physical and Policy Environments – Racial Segregation Racial Segregation – Racism and Discrimination Racism and Discrimination

Definition of Culture Definition of Culture

CultureCulture: The system of shared : The system of shared beliefs, values, customs, beliefs, values, customs, behaviors, and artifacts that the behaviors, and artifacts that the members of society use to cope members of society use to cope with their world and with one with their world and with one another, and that are transmitted another, and that are transmitted from generation to generation from generation to generation through learningthrough learning

Cultural Norms & Cultural Norms & Beliefs:Beliefs:Eating PatternsEating Patterns Food as culture Food as culture

– Preparation methodsPreparation methods– Eating Practices Eating Practices

Large Meal PreparationLarge Meal Preparation Social Context of Eating Social Context of Eating

– TextureTexture– Seasoning/Flavors/Aromas Seasoning/Flavors/Aromas

Self-expression through food and food Self-expression through food and food practices practices – Part of ethnic identityPart of ethnic identity– Preserves traditionsPreserves traditions

Ethnic Differences in Ethnic Differences in Body SatisfactionBody Satisfaction

0

10

20

30

40

50

60

Whites Blacks Latinos Asians

Low Medium High

Neumark-Sztainer et al, 2002

African American Body African American Body ImageImage

African-American women are African-American women are more accepting of larger body more accepting of larger body sizesize

Overweight or obese body sizes Overweight or obese body sizes and shapes are considered and shapes are considered healthy and attractivehealthy and attractive

Believe that men like women Believe that men like women with “meat on their bones”with “meat on their bones”

Excess weight does not hinder Excess weight does not hinder sexual activity or sexual activity or exercise/sportsexercise/sports

Latinas & Body ImageLatinas & Body Image

Less is knownLess is known Overall desire to be thinnerOverall desire to be thinner

– Want to be smaller than their current sizeWant to be smaller than their current size– Believe a slimmer figure is more attractiveBelieve a slimmer figure is more attractive– Not “rail thin”Not “rail thin”

Believe that media influences attitudesBelieve that media influences attitudes– Feel pressure to fit into mainstreamFeel pressure to fit into mainstream

22ndnd generation more concerned about generation more concerned about weightweight

Cultural Factors Cultural Factors Supporting Body ImageSupporting Body Image

However, African American women and However, African American women and Latinas are trying to lose weightLatinas are trying to lose weight

Less acculturationLess acculturation Stable family Stable family Stable social networksStable social networks Emphasis on personalityEmphasis on personality ““Real women have curves”Real women have curves”

Viladrich et al., 2009

Social and Family Roles:Social and Family Roles:Caregiving Caregiving

Barrier to preventative health behaviors Barrier to preventative health behaviors and self-managementand self-management

Cultural obligation for caregivingCultural obligation for caregiving– African Americans (4.3%) are more likely to African Americans (4.3%) are more likely to

be caring for grandchildren than are be caring for grandchildren than are Caucasians (1%); (U.S. Bureau of the Caucasians (1%); (U.S. Bureau of the Census, 2000)Census, 2000)

Strong Black “Matriarch” Strong Black “Matriarch” Many grandparent caregivers living Many grandparent caregivers living

below the poverty line (19%) (Census, below the poverty line (19%) (Census, 2000)2000)

Stress and DepressionStress and Depression

Blacks report more stressorsBlacks report more stressors Maternal depression in caregivers Maternal depression in caregivers

of infants and toddlers is of infants and toddlers is associated with poorer child associated with poorer child health status, household food health status, household food insecurity, and loss of federal insecurity, and loss of federal financial support and food stamps financial support and food stamps (Casey et al., 2004)(Casey et al., 2004)

SOCIOECONOMIC STATUSSOCIOECONOMIC STATUS

Socioeconomic StatusSocioeconomic Status

Higher education and income less Higher education and income less obesity and better dietsobesity and better diets

Higher neighborhood SES Higher neighborhood SES higher higher fruit and vegetable intakefruit and vegetable intake

Limited financial resources Limited financial resources associated with food insecurity and associated with food insecurity and limited accesslimited access

Age-Adjusted Prevalence of Age-Adjusted Prevalence of Obesity (BMIObesity (BMI30) by % of Poverty 30) by % of Poverty 1988-20101988-2010

0

10

20

30

40

50

60

70

1988-94 1999-2002 2003-6 2007-10

% O

bes

e

< 100% 100-199% 200-399% 400% +

Health U.S. 2011

5151

The Cost of Healthier The Cost of Healthier FoodsFoods

Drewnowski et al., 2004

FOOD MARKETINGFOOD MARKETING

Marketing WorksMarketing Works

People who watch food commercials eat more Choose high calorie

foods Most ads sell

unhealthy foods

Marketing WorksMarketing WorksHarris et al., 2009Harris et al., 2009

Children 7-11 y.o.Children 7-11 y.o.– watched a cartoon with food or other watched a cartoon with food or other

commercialscommercials– given goldfish as a snackgiven goldfish as a snack– those watching food ads ate 45% morethose watching food ads ate 45% more

Marketing WorksMarketing WorksHarris et al., 2009Harris et al., 2009

AdultsAdults– watched 16 min. show, 4 min of watched 16 min. show, 4 min of

commercialscommercials snack, nutrition & non-food adssnack, nutrition & non-food ads

– afterwards, they tasted 4 foods (ad lib)afterwards, they tasted 4 foods (ad lib)– those who saw snack ads ate the most, those who saw snack ads ate the most,

those who saw nutrition ads ate the leastthose who saw nutrition ads ate the least

Marketing WorksMarketing Works

Children & adolescents spend ~$200 Children & adolescents spend ~$200 billion/yr, food items take the top billion/yr, food items take the top spotsspots

Food companies invest heavily to Food companies invest heavily to increase sales and create brand increase sales and create brand loyaltyloyalty

Before age 8-10, children cannot Before age 8-10, children cannot understand that advertising is biasedunderstand that advertising is biased

RWJF 2008 Brief

FTC, 2008

ENVIRONMENTENVIRONMENT

Place of Residence

Health status and diet quality differ by area of residence– Southern vs. Midwest vs. West

Diet quality: Blacks born in the Caribbean > Blacks in Northern US > Southern US

Better diets in those born outside the US

Neighborhood and Neighborhood and Environmental Factors Environmental Factors Limited Food Availability in lower Limited Food Availability in lower

income and minority income and minority neighborhoodsneighborhoods– Fewer healthy food choicesFewer healthy food choices– Higher proportion of convenience Higher proportion of convenience

stores and local markets, fewer stores and local markets, fewer supermarketssupermarkets

– Poor quality produce in Poor quality produce in neighborhood storesneighborhood stores

Food Availability in Food Availability in Neighborhoods: East Harlem Neighborhoods: East Harlem Diabetes CoalitionDiabetes Coalition

Compared availability of Compared availability of diabetes-related foods in food diabetes-related foods in food stores in East Harlem (EH) to stores in East Harlem (EH) to those on the Upper East Side those on the Upper East Side (UES)(UES)– Low-fat or skim milkLow-fat or skim milk– High fiber or low carbohydrate High fiber or low carbohydrate

breadbread– Diet sodaDiet soda– Presence of any fresh producePresence of any fresh produce

Surveyed 99% of storesSurveyed 99% of storesHorowitz et al., 2004

Food Availability in Food Availability in Neighborhoods: The Neighborhoods: The ARIC StudyARIC Study Studied food stores in Maryland, Studied food stores in Maryland,

Minnesota, Mississippi, and North Minnesota, Mississippi, and North CarolinaCarolina

Blacks more likely to live in low Blacks more likely to live in low wealth areaswealth areas

Fewer supermarkets in lower Fewer supermarkets in lower wealth and Black neighborhoodswealth and Black neighborhoods

Morland et al., 2002a, 2002b

Food Availability in Food Availability in Neighborhoods: The Neighborhoods: The Community Health CouncilsCommunity Health Councils

In lower income and African American In lower income and African American areas in Los Angeles, CA:areas in Los Angeles, CA:– Higher proportion of convenience stores Higher proportion of convenience stores

and local markets, fewer supermarketsand local markets, fewer supermarkets– Lower availability of fresh fruits and Lower availability of fresh fruits and

vegetables, low-fat milk and low-fat snacksvegetables, low-fat milk and low-fat snacks– Fewer diabetic or low-salt sectionsFewer diabetic or low-salt sections– Poorer quality of produce (color, texture, Poorer quality of produce (color, texture,

consistency, cleanliness)consistency, cleanliness)Sloane et al., 2003

Restaurant Restaurant EnvironmentEnvironment White and mixed neighborhoods have

more full service restaurants Low-medium and medium wealth

neighborhoods have more fast food and carryout

Does it matter? – Presence of fast food restaurant in census tract

not associated with diet (Morland et al. 2002)– However, vegetable intake was positively

associated with restaurant availability of vegetables (Edmonds et al., 2001)Edmonds et al., 2001)

CONCLUSIONCONCLUSION

Institute of MedicineInstitute of MedicineAccelerating Progress in Accelerating Progress in Obesity Prevention GoalsObesity Prevention Goals

Make physical activity an integral and routine Make physical activity an integral and routine part of lifepart of life

Create food and beverage environments that Create food and beverage environments that ensure that healthy options are the routine, easy ensure that healthy options are the routine, easy choicechoice

Transform messages about physical activity and Transform messages about physical activity and nutritionnutrition

Expand the role of health care providers, Expand the role of health care providers, insurers, and employers in obesity preventioninsurers, and employers in obesity prevention

Make schools a national focal point for obesity Make schools a national focal point for obesity preventionprevention

IOM:IOM:Taking a Taking a systems systems approach to approach to addressing addressing obesityobesity

IOM ReportIOM Report