The Path to Obesity: Below Awareness and Beyond Individual Control

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The Path to ObesityBelow Awareness and Beyond
Individual Control

• Deborah Cohen, MD, MPH

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MAIN POINTS

• 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.

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Obesity

• 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

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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
gt300lbs)
Figure 1 Increasing prevalence of severe
obesity
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Continued Disparities, Although Similar Weight
Gain Across Socio-economic Strata
Source Truong and Sturm, AJPH, 2005
Sep95(9)1602-6
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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?

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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

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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

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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?

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Whats the Matter with Us ?

• Are we
• Stupid?
• Lazy?
• Morally inferior?
• Weak in character?
• Inherently defective?

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Even Experts Are Overweight

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

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

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The environment has more control over eating
than individuals do
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because eating is an AUTOMATIC BEHAVIOR that
occurs in response to the environment
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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

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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

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1. Brain Dopamine Response to Food Stimulation
Neutral
Food
1.5
0
ml/g
(Bmax/Kd)
Desire for Food
p lt 0.005
p lt 0.01
Neutral
Food
Change Bmax/kd
Volkow et al., Synapse 2002
DA in striatum is involved with desire and
motivation for food consumption
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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.
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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
  container.

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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
  characteristics
• Rolls BJ, Morris EL, Roe LS. The American journal
  of clinical nutrition. Dec 200276(6)1207-1213.

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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
  200377(5)1164-1170.

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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

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Results People with Self-Refilling Bowls Ate 73
More

• People given self refilling bowls ate 73 more
• The groups perceived that they ate the same
  amount
• 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)

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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
200537(5)242-245.
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3. Hardwired Survival Strategies Dietary
Heuristics

• Variety is preferred
• Our heritage of being hunter/gatherers means we
  are more likely to select items in abundance.

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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
  colors
• 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
200424455-79.
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Increase in Sales of Fruits and Vegetables Caused
by Doubling of Display Space
Curhan R. J Marketing Research 197411286-94
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CHIPS ARE IN SEASON!
Doubling shelf space increases sales by 40
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Placing products at eye-level triples sales
compared to placement on second or bottom shelf
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End aisle display increases sales 2-5 fold
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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
  fat

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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
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5. Natural tendency to conserve energy

• Eat as much as you can when food is
  available
• Rest as much as you can,
• when you dont have to look for food.
• Tendency to favor convenience foods

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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.
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6. MIRROR NEURONS AT WORKCompany Increases
Consumption

• 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
199251(1)121-125.
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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
  crackers

Chartrand T. The Role of Conscious Awareness in
Consumer Behavior. Journal of Consumer
Psychology 200515(3)203-210.
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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.
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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
  Psychology

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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

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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)  
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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)

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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

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Subliminal Priming Influences Consumption
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People Drank More When Shown the Happy Face, With
No Insight
http//psp.sagepub.com/cgi/content/abstract/31/1/1
21
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Rated Drink More Favorably When Exposed to Happy
Face, Again No Insight
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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

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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)

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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

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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.

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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
200431(3)599-608.
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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)

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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
199874(5)1252-1265.
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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.

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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
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Summary

• 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

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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

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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

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Ulysses and the Sirens
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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
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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.

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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
  diets
• Education alone is NOT effective

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Implications Change the Food Environment

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

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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
  profitable
• People decisions are influenced depending on how
  choices are framed (e.g. gain vs. loss)

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In Many Circumstances Negative Messages Are More
Effective

• People detect and pay more attention to negative
  stimuli
• 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

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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
  calories.
• http//www.health.gov/DIETARYGUIDELINES/dga2005/re
  port/HTML/D3_DiscCalories.htm

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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
addiction
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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

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Cues to Refrain from Smoking

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Few Cues to Refrain from Eating
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How Can We Do This For Discretionary Calories?

• Change Environments worksite, hospital, clinic
  environments
• Sponsor media and social marketing campaigns
  that counter aggressive marketing of
  discretionary calories
• Advocate for more government regulation
• Labeling and point of purchase warnings

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Great Britains Labeling Campaign
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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
Responsibility

• Individuals cannot control what they are exposed
  to
• Individuals cannot prevent automatic reactions to
  food
• Individuals have a limited capacity to resist the
  environment

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Billboard Ban in Sao Paulo, Brazil
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Billboard Control in the US

• Billboards prohibited in
• Vermont,
• Maine,
• Hawaii
• Alaska
• Rhode Island and Oregon prohibit the construction
  of new billboards

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Rate Local Restaurants

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

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There are lots of opportunities for change.
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Dont Forget Physical Activity Important in the
Energy Balance Equation

• Streets
• Sidewalks
• Parks
• Recreational facilities
• Schools and worksites
• Transportation systems

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Summary

• 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

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Conclusion

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

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More at www.healthscaping.org
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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