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The Path to Obesity: Below Awareness and Beyond Individual Control


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Title: The Path to Obesity: Below Awareness and Beyond Individual Control

The Path to ObesityBelow Awareness and Beyond
Individual Control
  • Deborah Cohen, MD, MPH

  • Our health is largely determined by our behavior
  • The environment influences our behavior
  • People typically respond automatically to the
    environment, often without awareness
  • Without awareness or insight, people cannot
    easily control their automatic reactions
  • Society needs to create environments that
    facilitate healthy behaviors.

  • Becoming the most important actual cause of
    morbidity and mortality in the US.
  • Two-thirds of Americans are overweight or obese
  • Responsible for gt75 billion in annual health
    care costs

Obesity Affects the Whole Population
From the Intersalt Study Rose, The Strategy of
Preventive Medicine
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Changes in Population BMI, 1986- 2000,
BRFSS (Roland Sturm, 2003)
2000-2005 24 gt30 50 gt40 75 gt50 (55, Wt
Figure 1 Increasing prevalence of severe
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Continued Disparities, Although Similar Weight
Gain Across Socio-economic Strata
Source Truong and Sturm, AJPH, 2005
Obesity Is a Global Epidemic
  • Obesity is causally related to many chronic
    diseases, including diabetes and heart disease
  • More people suffer from overweight and obesity
    than malnutrition worldwide
  • Why is this happening?

Classic Economic Theory
  • People are rational
  • They make choices based upon what they believe is
    in their own best interest
  • If they are overweight or obese, its a result of
    their own choices

Classic Economic Theory Is Wrong in This Case
  • People rationalize
  • People often have no idea why they make the
    decisions that they do
  • If they are overweight or obese, its primarily
    because of their environment

Why Should the EnvironmentAffect Us So Much?
  • Most people know that eating too much and
    exercising too little makes us gain weight
  • Cant we just refuse to eat junk food?
  • Cant we limit snacking?
  • Cant we follow diets?

Whats the Matter with Us ?
  • Are we
  • Stupid?
  • Lazy?
  • Morally inferior?
  • Weak in character?
  • Inherently defective?

Even Experts Are Overweight
  • Doctors
  • Nurses
  • Dieticians
  • Vegetarians
  • Members of the clergy
  • People who exercise regularly
  • People of courage
  • Smart people
  • Parents and grandparents

Is it plausible that 2 out of 3 Americansare
consciously deciding to be overweight or obese?

The environment has more control over eating
than individuals do
because eating is an AUTOMATIC BEHAVIOR that
occurs in response to the environment
Eating Is an Automatic Behavior
(To be considered automatic, it doesnt have to
be automatic all the time)
  • Lack of awareness
  • Lack of intent
  • Lack of effort
  • Lack of control, meaning the inability to stop if
    we choose

10 Mechanisms that Lead to Excessive Eating
Without Awareness or Insight
  1. Physiological response to food and images of food
  2. Inability to judge volume or calories
  3. Hardwired survival strategies foraging, variety
  4. Inborn preferences for sugar and fat
  5. Natural tendency to conserve energy
  6. Mirror neurons
  7. Conditioning
  8. Priming
  9. Stereotype Activation
  10. Limited cognitive capacity

1. Brain Dopamine Response to Food Stimulation
Desire for Food
p lt 0.005
p lt 0.01
Change Bmax/kd
Volkow et al., Synapse 2002
DA in striatum is involved with desire and
motivation for food consumption
The message that you get when dopamine is
liberated in striatumin this case, the dorsal
striatumis that you need to get into action to
achieve a certain goal. It is a powerful
motivator. It is extremely hard to overcome these
impulses with sheer willpower.   Nora D. Volkow,
Director of the National Institute on Drug Abuse
and a pioneer in the study of addiction.
2. Inability to Judge Volume
  • We are unaware of how much we eat
  • We dont feel more full when we overeat
  • We cannot judge portion sizes
  • We take our cues for how much to eat based on
    what is available including the size of the

Portion Sizes Play a Role in How Much We Eat
  • Subjects consumed 30 more calories when offered
    the largest portion than when offered the
    smallest portion
  • Larger portions led to greater calorie intake
    regardless of serving method and subject
  • Rolls BJ, Morris EL, Roe LS. The American journal
    of clinical nutrition. Dec 200276(6)1207-1213.

Portion Sizes Affect Intake Among Children
  • Doubling a portion of an entrée increased intake
    at lunch by 25
  • Children increased the average
  • size of their bites
  • No compensatory decreases in the
  • intake of other foods
  • The children were largely unaware of changes in
    portion size
  • Orlet Fisher J, Rolls BJ, Birch LL. The American
    journal of clinical nutrition. May

Visual Cues Influence Consumption
  • Subjects received soup in different colored bowls
  • Half the subjects had soup in self-refilling soup
    bowls, half had normal bowls
  • They were told to rate the soup and estimate how
    much they ate

Results People with Self-Refilling Bowls Ate 73
  • People given self refilling bowls ate 73 more
  • The groups perceived that they ate the same
  • Both groups thought they ate less than they did
  • People in the self refilling bowl condition did
    not feel more full than the other group
  • (Wansink et al, Obesity Research 20051393-100)

Popcorn Study People Eat More When Given More
  • Moviegoers were given large or medium containers
    of popcorn that were fresh or stale (2 weeks old)
  • Those given large containers of fresh popcorn ate
    45 more than those given medium containers
  • People given large containers of
    stale popcorn ate 34 more than
    those given medium containers
  • Lesson People given more food
  • will eat more food, even if it tastes
  • bad

Wansink B, Kim J. J Nutr Educ Behav. Sep-Oct
3. Hardwired Survival Strategies Dietary
  • Variety is preferred
  • Our heritage of being hunter/gatherers means we
    are more likely to select items in abundance.

Variety Increases Consumption
  • Having many different choices (colors, flavors)
    increases consumption
  • People offered an assortment of 10 colors of
    jellybeans ate 43 more than the group offered 7
  • People offered the jellybeans in a mixed
    assortment ate 69 more than the group offered
    jellybeans sorted by color

Wansink B. Environmental factors that increase
the food intake and consumption volume of
unknowing consumers. Annu Rev Nutr
Increase in Sales of Fruits and Vegetables Caused
by Doubling of Display Space
Curhan R. J Marketing Research 197411286-94
Doubling shelf space increases sales by 40
Placing products at eye-level triples sales
compared to placement on second or bottom shelf
End aisle display increases sales 2-5 fold
4. Inborn Preferences for Sugar and Fat
  • Newborns prefer sweet tastes
  • Fat provides strong reward signals in brain
  • Its very easy (and profitable) to sell sugar and

Snack Foods Are Everywhere
  • Car washes
  • Book stores
  • Hardware stores (Home Depot)
  • Gas stations
  • Office buildings (vending machines)
  • Health clubs/gyms
  • Video stores
  • Car repair shops

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Discretionary Calories ConsumptionKP-HEAL sites,
Northern California
5. Natural tendency to conserve energy
  • Eat as much as you can when food is
  • Rest as much as you can,
  • when you dont have to look for food.
  • Tendency to favor convenience foods

Convenience Increases Candy Consumption
  • Secretaries ate 46 more Hersheys kisses when
    the candy was placed on desks in clear jars than
    when in opaque jars
  • They ate 5.6 more chocolates per day when candy
    was placed on desk than when it was placed across
    the room

Wansink B, Painter JE, Lee YK.. Int J Obes. May
200630(5)871-875. Painter JE, Wansink B,
Hieggelke JB. Appetite. Jun 200238(3)237-238.
6. MIRROR NEURONS AT WORKCompany Increases
  • One companion increases consumption by 33
  • Two companions, 47
  • Three companions, 58
  • With 7 or more people, 96 more
  • These numbers are related to how much time people
    spend at the table

de Castro JM, Brewer EM.. Physiol Behav. Jan
Mimicking Leads to Increased Liking Animal
Crackers and Goldfish
  • In a study the interviewer and the participant
    were both given a bowl of goldfish and a bowl of
    animal crackers to munch on while they talked.
  • In one condition, the interviewer ate the
    goldfish, in the other, he ate the animal

Chartrand T. The Role of Conscious Awareness in
Consumer Behavior. Journal of Consumer
Psychology 200515(3)203-210.
Mimicking Leads to Increased Liking Animal
Crackers and Goldfish
  • People unconsciously mimicked consumption of
    either goldfish or animal crackers, depending on
    what the interviewer ate.
  • Participants more likely to report preferring the
    product they ate, which was determined by
    interviewers choice.
  • No insight among participants

Chartrand T. The Role of Conscious Awareness in
Consumer Behavior. Journal of Consumer
Psychology 200515(3)203-210.
Ice Cream Taste Test
  • Participants invited to judge ice cream
    Confederate took a sample of ice cream first
  • Participants took a portion that was the same as
    the confederate
  • How much they ate depended on scoop size the
    confederate took
  • Participants were unaware of why they chose the
    amount of ice cream
  • Dijksterhuis et al (2005) Jl of Consumer

7. Conditioning Pavlovs Dog
  • Pavlov conditioned dogs by ringing a bell when
    food was available
  • Dogs salivated when they heard the bell
  • Humans are also conditioned to feel hungry
  • stimulated by symbols, smells, memories
    associated with food, and especially food itself

Our genes have changed little, but in our
environment, we are now surrounded by high-fat,
high-sugar foods. And this abundance is
undoubtedly a major factor contributing to the
rise in obesity. Conditioning responses are
incredibly powerful with food when I go past a
vending machine and I see chocolates I like
very much, I desire the chocolate even though Im
not hungry. But if those chocolates werent
there, it would be the last thing on my
mind. Nora Volkow, MD (NIDA Director)  
Marketing Creating Associations Between a
Product and Human Desires
  • Branding- people buy brand, rather than
  • product
  • Celebrity endorsements
  • Appeals to needs (fun, power, status, sex)

8. Priming
  • Sensitizing someone to activate specific memories
    or associations so that it influences a
    subsequent behavior.
  • Works when people are unaware of the intention or
    existence of the prime

Subliminal Priming Influences Consumption
People Drank More When Shown the Happy Face, With
No Insight
Rated Drink More Favorably When Exposed to Happy
Face, Again No Insight
9. Automatic Stereotype Activation
  • People respond to others based upon stereotypes
    and that the responses are unintended, efficient,
    and outside the awareness of the perceiver.
  • People automatically have favorable attitudes
    towards people who look like they do, and
    negative reactions to those who appear different

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10. Limited Cognitive Capacity
  • Human cognitive capacity is limited
  • We can only think about one thing at a time, so
    everything else functions automatically
  • Human beings can process only 40-60 bits per
    second - equivalent to a short sentence
  • However their entire processing capacity, which
    includes the visual system and the unconscious,
    is estimated to be 11 million bits per second.
  • The brain needs mechanisms to perceive the
    environment and react without awareness

Two Brain Processes
  • 1) Cognitive thinking, careful, considered
    decisions (lt 5)
  • 2) Impulsive, automatic happens quickly, resort
    to this when theres too much information, or
    under stress, tired, or pre-occupied (gt95)

The Brain Relies on Shortcuts Called Heuristics
  • Simple, efficient rules, hard-coded by
    evolutionary processes which have been proposed
    to explain how people make decisions, come to
    judgments, and solve problems-- shortcuts
  • Brands
  • Prices
  • Salience
  • What other people do
  • Appearance/ color/ size/ shape

Fruit Salad or Chocolate Cake?
  1. Participants asked to choose between fruit salad
    and chocolate cake
  2. One group asked to memorize a 2- digit number,
    the other group asked to memorize a 7- digit
    number before choosing the snack.

Reduced Processing Resources Leads to More
Chocolate Cake
Reduced Processing Resources Leads to More
Chocolate Cake
  • 62 of the participants who had to memorize 7
    digits chose chocolate cake compared to 45 of
    those who were asked to memorize 2 digits
  • Interpretation Impulsive responses dominated
    when people were preoccupied with memorizing
    numbers. Fewer cognitive resources available to
    carefully consider the choices.
  • 62 of the participants who had to memorize 7
    digits chose chocolate cake compared to 45 of
    those who were asked to memorize 2 digits
  • Interpretation Impulsive responses dominated
    when people were preoccupied with memorizing
    numbers. Fewer cognitive resources available to
    carefully consider the choices.

Shiv B, Nowlis S. The Effect of Distractions
While Tasting a Food Sample The Interplay of
Informational and Affective Components in
Subsequent Choice Journal of Consumer Research
Self-Control Has Limits
  • Self-control is limited and behaves like a
    muscle it fatigues over time
  • Dieters relapse under stress and at the end of
    the day
  • Studies indicate that dieters have impaired
    executive functioning (decision-making,
    thinking tasks due to preoccupation)

Chocolate Chip Cookie Trial
  • Subjects in a laboratory setting told not to eat
    before coming. Divided in 3 groups
  • Fresh baked chocolate chip cookies and
    candy and radishes on the table, and
    subjects told to help themselves
  • Cookies present, but subjects told to
    only eat the radishes
  • No cookies or food available

Baumeister RF, Bratslavsky E, Muraven M, Tice DM.
Ego depletion is the active self a limited
resource? J Pers Soc Psychol. May
Refusing Chocolate Chip Cookies Takes a Toll
  • Group with no food available worked 21 minutes
    trying to solve a puzzle
  • Cookie eating group worked 19 minutes
  • Cookie refusing group gave up after 8 minutes.
    They reported feeling more tired and quit as soon
    as they felt the urge
  • Baumeister RF, Bratslavsky E, Muraven M, Tice DM.
    Ego depletion is the active self a limited
    resource? Journal of personality and social
    psychology 199874(5)1252-65.

Lack of Insight is Common
I don't buy this at all. I am fifty nine years
old and weight about three hundred pounds and I
honestly and truly believe i am completely in
charge of my weight. I know exactly what to do to
not only lose weight but to keep it off but I
make a conscious decesion to eat what I eat when
I eat it. It is my choice to not exercise or eat
right. I enjoy eating and I enjoy eating foods I
know are not healthy. I also choose to be a couch
potato I enjoy nothing more then a pizza and
watching a movie. I may not live as long as other
but I will live happy. --Bill
  • Definite causal relationships between environment
    and eating behaviors
  • Environment dominates and eating is a responsive,
    automatic behavior
  • We cant control what we are unaware of

Invisible Weight Gain Increase in Calories is
Below Awareness
  • Most people gain weight slowly, about 2 pounds
    per year
  • Equivalent to an extra 20 calories a day
  • 20 calories lt 1 teaspoon of ranch salad
    dressing, or 2 sticks of gum, or ¼ piece of toast

Why Are Some People Overweight and Not Others?
  • Different environments
  • Different sensitivities to the environment
  • Different genetic predispositions
  • Its VERY hard to change people easier to change
    their environments

Ulysses and the Sirens
Marketing Is the Modern Siren
Most people need protection from the food
industrys aggressive marketing. The marketing
industry spends billions on research to determine
how they can promote impulsive behaviors that
result in more sales. They conduct surveys,
observations, focus groups, and test marketing
Example Eye-Tracking Technology
  • What subjects look at in what sequence and for
    how long.
  • How many times the respondent fixated on any
    given element
  • The more attention people give to a product, the
    more likely they are to buy it.

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Unseen is unsold! Some brands are seen by less than 10 of respondents while nearly all respondents see other brands. We'll tell you which ones and why.

People Need Help. . .
  • Resisting environmental cues and marketing ploys
    that make us eat too much and too often
  • Obtaining the appropriate balance of fruits,
    vegetables, and other nutrients to optimize their
  • Education alone is NOT effective

Implications Change the Food Environment
  • Reduce cues to eat
  • Reduce portion sizes
  • Reduce availability of high calorie, low nutrient
  • and/or
  • Interrupt automatic responses to make cues
  • (e.g. labeling, counter-advertising)

USDA Policy Prohibiting Negative Messages Should
Be Reversed
Messages of nutrition education are consistent
with the Dietary Guidelines for Americans and
stress the importance of variety, balance, and
moderation, and do not disparage any specific
food, beverage or commodity.
  • No scientific rationale to support positive
    messages over negative ones
  • As early as 1929, negative messages found to be
  • People decisions are influenced depending on how
    choices are framed (e.g. gain vs. loss)

In Many Circumstances Negative Messages Are More
  • People detect and pay more attention to negative
  • Negative framing more effective if the means of
    persuasion are based upon message claims, rather
    than a short-cut (heuristic)
  • Used in political campaigns because it works
    negative messages are more memorable

The USDA Identifies Discretionary Calories as
CENTRAL to the Obesity Epidemic
  • Most people have no discretionary calories
    because of their sedentary lifestyle and
    selection of energy-dense foods.
  • The USDA food modeling method counts most solid
    fats and all added sugars as "discretionary."
    Alcoholic beverages also count as discretionary
  • http//

How Do We Avoid Discretionary Calories?
One of the therapeutic interventions for drug
addicts is to teach them to avoid places
associated with their habit. But how do you do
that with food? Its impossible.      Nora D.
Volkow, Director of the National Institute on
Drug Abuse and a pioneer in the study of
Tobacco Control Lessons Change the Environment
  • Techniques that worked
  • Restricting places where smoking is allowed
    (Clean air laws)
  • Reducing tobacco accessibility (removing vending
    machines, placed behind counters)
  • Taxing cigarettes
  • Media campaign making smoking unattractive
  • Frequent cues reminding people not to smoke

Cues to Refrain from Smoking

Few Cues to Refrain from Eating
How Can We Do This For Discretionary Calories?
  • Change Environments worksite, hospital, clinic
  • Sponsor media and social marketing campaigns
    that counter aggressive marketing of
    discretionary calories
  • Advocate for more government regulation
  • Labeling and point of purchase warnings

Great Britains Labeling Campaign
7-11 Fountain Drink Choices
32 oz 400 calories
40 oz 500 calories
44 oz 550 calories
52 oz 650 calories
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Portion Symbols
  • Skinny (lose weight)
  • Average (maintain weight)
  • Fat (gain weight)

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Controlling the Food Environment is a Societal
  • Individuals cannot control what they are exposed
  • Individuals cannot prevent automatic reactions to
  • Individuals have a limited capacity to resist the

Billboard Ban in Sao Paulo, Brazil
Billboard Control in the US
  • Billboards prohibited in
  • Vermont,
  • Maine,
  • Hawaii
  • Alaska
  • Rhode Island and Oregon prohibit the construction
    of new billboards

Rate Local Restaurants
  • Restaurants are currently inspected and regulated
    for infectious diseases
  • Rate on meeting USDA dietary guidelines and risk
    for chronic disease

There are lots of opportunities for change.
Dont Forget Physical Activity Important in the
Energy Balance Equation
  • Streets
  • Sidewalks
  • Parks
  • Recreational facilities
  • Schools and worksites
  • Transportation systems

  • Eating is an automatic behavior
  • Obesity is driven by exposure to food and food
    cues in an environment with excess calories
  • Many food cues are below the level of our
    conscious awareness and are designed to promote
    impulsive, automatic behaviors
  • People cannot control what they are unaware of

  • We cannot change peoples automatic responses to
    the environment
  • The environment is the source of health and
  • We can create healthy environments!

More at
Another Blog Comment
  • What a crock of utter nonsense to say because
    some or even most people overeat it is "proof"
    that willpower doesn't work. It is proof only
    that most people are lazy stupid slobs.
    Environmental factors influencing them include
    lazy stupid researchers
  • -- Bob
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