HEALTH PROMOTION: SOCIAL CHANGE AND PHYSICAL ACTIVITY

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HEALTH PROMOTION SOCIAL CHANGE AND PHYSICAL
ACTIVITY

• John C. Peters, PhD
• Nutrition Science Institute
• The Procter Gamble Company

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TODAY An Obesity Epidemic
Obesity is the health problem of the century.
Dr. Jeffrey Koplan, Director, Centers for Disease
Control and Prevention
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WHO Obesity Report

• Global projections for obesity for the next
  decade are so serious that public health action
  is urgently required
• It is necessary to develop new preventive public
  health strategies which affect the entire society
• Obesity is todays principal neglected public
  health problem

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US TRENDS IN OBESITY

• Overweight BMI gt25
• Adults 61 97M (gt20 yrs)
• F 50 47M
• M 59 50M
• Obese BMI gt30
• Adults 26 39.8M
• F 25 23M
• M 19 17M
• 14 children adolescents

available at http//www.niddk.nih.gov/health/nutr
it
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Available at www.cdc.gov/nccdphp/dnpa/obesity/tre
nd/maps/slide
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GRAYING OF AMERICA

• ? Number of older adults
• Today 34M, 13, 18
• 2030 70M, 20, 15
• 5,574 Americans turn 65 each day
• ? Number of minorities
• 2000 16
• 2030 25
• 85 population
• 2000 4.2 M
• 2030 8.9 M

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OVERWEIGHT OBESE BY AGE GROUPS
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BMI

• 33 congregate and home delivered meal
  participants have BMIs 22-27
• 32 home delivered meal participants have BMIs
  lt22 (underweight)
• 42 congregate meal participants have BMIs gt27
  (overweight)

Natl Eval ENP, 1993-1995 (Mathematica)
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PHYSICAL ACTIVITY

• Multiple health benefits for older adults
• ? muscle bone strength
• ? lean muscle, ? body fat
• Helps control weight
• May ? symptoms depression anxiety

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OVERWEIGHT EXERCISE
94-96 CSFII
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MOBILITY LEISURE TIME PA NUTRITION PROGRAM
PARTICIPANTS
Natl Eval ENP, 1993-1995 (Mathematica)
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FUNCTIONAL STATUS HDM Participants

• 65 unable to perform gt1 ADLs or IADLs without
  assistance
• 37 unable to walk without assistance
• 64 unable to shop for groceries
• On average, impaired in 2 ADLs 2 IADLs

Natl Eval ENP, 1993-1995 (Mathematica)
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WHATS CAUSING THE OBESITY EPIDEMIC?

• Biology
• Physiology gone astray?
• Environment
• Is it the way we live?
• Societal Values
• Our underlying beliefs and values?

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BIOLOGY

• Genes clearly affect body weight
• understand the physiology of energy balance
• Our genes can explain differences between people,
  but cannot explain the rapid increase in obesity
  in all groups over the past couple of decades
• Environment must be playing a role in susceptible
  people

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PIMA INDIANS
35.5
35
30.8
30
25.1
24.8
25
US
20
Mexico
BMI (kg/m2)
15
10
5
0
Men
Women
Adapted from Ravussin, et al., 1994
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• We have a mismatch between our physiology and our
  environment

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Body Fat Mass
Environmental Pressures to Reduce Physical
Activity
EIn
EOut
Environmental Pressures to Eat
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WHAT ARE THE CAUSES?

• Biology
• Physiology gone astray?
• Environment
• Is it the way we live?
• Societal Values
• Our underlying beliefs and values?

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WHATS CAUSING THE PROBLEM?

• Tendency to become fat is fostered by our
  American lifestyle
• Lack of physical activity combined with
  abundant, ubiquitous, inexpensive, tasty,
  high-calorie food
• 170,000 fast food restaurants
• One chains goal lt4 min. from anywhere in US
• 3 M soda vending machines
• At supermarkets, schools, video stores, soccer
  fields, gas stations, etc.

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What are the relative contributions of overeating
vs. physical inactivity in the etiology of
obesity?

• Incomplete data, difficult to quantify separate
  components
• Mostly descriptive, observational studies
• Focus has been mostly on proximal factors

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WHAT FACTORS IN THE ENVIRONMENT PROMOTE ENERGY
INTAKE?

• Portion size
• High fat/energy dense foods
• High glycemic index foods
• Soft drinks
• Sugar
• High accessibility of food
• Low cost of food
• Great taste of food
• Variety
• Advertising of food

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SERVING VS. PORTION SIZES

• Serving size based on the USDA Food Guide
  Pyramid used on food labels
• Portion size amount of a specific food an
  individual eats
• Portion sizes vary
• gender
• activity level
• age
• appetite
• where and when food is obtained and eaten

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HOW DO THEY MATCH UP?
All medium servings
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PORTION SIZES HAVE INCREASED OVER THE YEARS
2.3 oz
6.9 oz
6.5 oz
20 oz
1.1 oz
3.7 oz
FrenchFries
Soft Drink
Candy Bar
Nutrition Action, 2001.
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IMPACT OF LARGER PORTIONS

• Girls women drank 17 oz when served a large
  size soda only 9 oz when served a small.
• On average, people ate 165 candy-coated chocolate
  bits when given a 2 lb bag 112 when given a 1
  lb bag.
• People eat 50 more hedonistic foods, like
  candy, chips, crisps, popcorn, when they come in
  bigger packages.
• With other foods (non-indulgent foods), the
  increase is usually 25.

B Wansink, Director, Food and Brand Research Lab
University of Illinois Champaign-Urbana
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Energy Intake (kcal/day)Adults 20 years and over
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What Factors in the Environment Promote Low
Levels of Physical Activity?

• Declining need for physical labor at work
• Elimination of physical activity in schools
• Reductions in physical activity required for
  daily living
• Physical environment, transportation
• Competition from attractive sedentary activities
• Television, video/DVD, video/computer games,
  internet

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DECLINE IN EE DUE TO TECHNOLOGY (kcals.yr-1)

• Female Male
• Reliance on elevators / escalators 4160
  4485
• Reliance on remote control 728 819
• Decrease in work-related activity 13,000 13,000
• 50 kcal per day
  17,888 18,304
• Equivalent to 2.3 kg (5.1 lb) of fat mass

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Traditional community design encourages physical
activity
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Modern community design discourages physical
activity
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NEIGHBORHOOD COMPARISON

• Traditional development
• Network
• grid-like street pattern
• many access points
• Land use
• high residential densities
• mixture and proximity of use
• Design
• contiguous sidewalks
• variation in housing size and design

• Suburban development
• Network
• circuitous streets, cul-de-sacs
• limited access points
• Land use
• large home lots, low density
• segregated, clustered land use
• Design
• no or disconnected sidewalks
• little variation in housing

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Daily Participation Physical Education in High
School
Boys
Girls
Percent
Source CDC, National Youth Risk Behavior Survey.
Year
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DECREASED ACTIVITY IN SCHOOLS

• Assume PE time ? from 50 to 30 mins. wk-1
  and recess time ? from 30 to 15 mins.
  day-1
• Average energy cost of activity to be 6.0 METS
• Children are active 50 of time
• (6 - 2) METs x 45 kg x 20/60 60.0
  kcal.day-1
• (6 - 2) METs x 45 kg x 7.5/60 22.5
  kcal.day-1
• 82.5 kcal.day-1
• Equivalent to 1.9 kg per school year (180
  days)

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TRENDS OF PARTICIPATION IN LEISURE-TIME PHYSICAL
ACTIVITY BY ADULTS, NHIS
Percent
Years
CDC
Source Physical Activity and Health, A Report of
the Surgeon General, 1996
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Body Fat Mass
EIn
EOut
Palatable, low-cost, easily available foods
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THE CAUSES OF OBESITY ARE ...

• so manifold and so basic as to be inseparable
  from the way we live.
• Margaret Talbot New America Foundation

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WHAT ARE THE CAUSES?

• Biology
• Physiology gone astray?
• Environment
• Is it the way we live?
• Societal Values
• Our underlying beliefs and values?

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OUR SOCIETY HAS ALWAYS ASPIRED TO

• Have abundant, accessible, affordable food supply
• Reduce amount of physical labor required for
  daily living
• Increased leisure, freedom of choice
• Have the good life

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• Our aspirational values are out of date in the
  environment we have built

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SOCIAL / CULTURAL DRIVERS

• Productivity -- provides the means to achieve
  the good life
• Leads to increased demand for more technology to
  increase productivity
• Leads to increased pace of life and time pressure
  
• Leads to increased demand for convenience
• convenience/comfort foods
• less physical activity
• more sedentary leisure/entertainment

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THE SEDENTARY LIFE

• Major cause of death in the US
• Sedentary Death Syndrome (SeDS) 1 of top 3
  causes of all-cause mortality in US
• 15 of 1.6 million chronic health conditions due
  to sedentary lifestyle alone

source Presidents Council on Physical Fitness
Sports. Series 3, No. 16
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COSTS OF SEDENTARY LIFESTYLE

• Physical inactivity accounts for 15 of US
  health care budget
• CVD 298.2B
• Type 2 Diabetes 98B
• 30 reduction achieved by those walking 2.5 hr/wk
• 15 lb. weight loss reduces risk by 60 saves
  US health system 58B/yr

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ECONOMIC BENEFITS OF PHYSICAL ACTIVITY

• In 14 yr study, unfit employees had twice the
  injury cost as fit employees (Cady 1985)
• Physically active employees spent 217 per person
  less on medical claims had 21 hr / person less
  of sick time (Gettman 1986)
• A zero increase in medical costs was reported for
  company with fitness program 35 increase in
  medical cost for one with no fitness program
  (Shepard 1992)

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WHAT DO WE NEED TO DO?

• Recognize that the environment is a reflection
  of our collective values as a society
• What are updated values for the new millennium?
• How can we build demand for healthy behaviors and
  a healthier environment?

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ELEMENTS OF SUCCESSFUL SOCIAL CHANGE

• A Crisis
• Science Base
• Economics
• Spark Plugs
• Coalition Building

• Advocacy
• Government Intervention
• Mass Communication
• Change Environment/Policy
• A Plan

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WHERE TO BEGIN?

• Explore most effective way to define the crisis
• Develop quantitative understanding of the energy
  imbalance driving the trend
• Develop plan for changing societal values
  long-termwhat is the new value equation?
• Must make economic sense
• Look for sustainability and incentives
• Build cognitive skills into education curriculum

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WHERE TO BEGIN?

• Look for ways to motivate change within existing
  value structure, i.e., look for opportunities
  that dont compete with current values
• Pilot innovative approaches that work within
  existing values, or that build new values (local,
  regional, national)

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SUMMARY

• We can no longer rely on biology (instinct) to
  maintain energy balance
• We need to provide the knowledge, skills,
  opportunity and reinforcement of healthy
  behaviors to prevent obesity (intellect)
• This will require coordinated effort among all
  sectors of societydriving toward a new set of
  social valueswe need to create demand for
  healthy behaviors and a healthy environment

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