>> GOOD AFTERNOON, EVERYONE. I'M FRANCIS COLLINS, DIRECTOR OF THE NIH. IT'S A PLEASURE TO WELCOME YOU ALL TO THIS AFTERNOON'S LECTURE. THIS IS THE ROBERT S. GORDON JR. LECTURE IN EPIDEMIOLOGY. ONE OF THE ESPECIALLY-NAMED LECTURES THAT OCCURS AS PART OF OUR WEDNESDAY AFTERNOON LECTURE SERIES. LIKE TO EXPRESS A SPECIFIC WELCOME TO STUDENTS FROM AMERICAN UNIVERSITY THAT HAVE JOINED US TODAY. THANK YOU ALL FOR BEING HERE. WE'RE DELIGHTED TO HAVE YOU IN OUR MIDST, AND ALSO WELCOME TO PEOPLE WHO ARE WATCHING BY VIDEO. I KNOW WHAT WE SEE HERE IN THE AUDITORIUM IS ONLY A FRACTION OF THOSE WHO ARE GOING TO BE LISTENING TO PROFESSOR KULLER'S PRESENTATION. LET ME SAY A WORD ABOUT ROBERT S. GORDON JR., FOR WHOM THIS LECTURE THE NAMED. THERE'S INFORMATION ABOUT THIS IN YOUR PROGRAM. THIS LECTURE IS PRESENTED ANNUAL TO TO A SCIENTIST WHO HAS MADE CERTAIN CONTRIBUTIONS IN THE FIELD OF EPIDEMIOLOGY. THE RECIPIENT IS SELECTED BASED ON THE ADVICE AND RECOMMENDATION OF SENIOR EPIDEMIOLOGIES HERE AT NIH. THIS IS THE 18th YEAR THIS AWARD HAS BEEN GIVEN AND IF YOU LOOK IN YOUR PROGRAM, YOU'LL SEE THE DISTINGUISHED LINEUP OF PREVIOUS PRESENTERS OF THE GORDON LECTURE. ROBERT GORDON WAS SOMEONE DEVOTED MORE THAN 30 YEARS OF EXCEPTIONAL SERVICE TO THE NSERVING IN NUMEROUS POSITIONS. HE WAS SOMEBODY WITH EXTENSIVE KNOWLEDGE AND EXPERIENCE IN THE CLINICAL SCIENCES, AND LED HIM TO BECOME A CHIEF ADVISOR FOR CLINICAL PRACTICE AND RESEARCH FOR TWO NIH DIRECTORS. HE WAS ALSO AN EARLY ORGANIZER OF EFFORTS TO ADDRESS THE EMERGING PROBLEM OF HIV/AIDS AND BECAME A KEY COORDINATOR AT NIH FOR AIDS RESEARCH. HE ALSO MADE IMPORTANT CONTRIBUTIONS TO INTERINSTITUTE POLICY AND MANAGEMENT ISSUES REGARDING EPIDEMIOLOGY, CLINICAL TRIAL AND THE HEALTH EFFECTS OF ENVIRONMENTAL HAZARDS. EACH YEAR WE RECOGNIZE THOSE CONTRIBUTIONS BY THIS SPECIAL LECTURE. THIS YEAR'S RECIPIENT OF THE GOR DAN LECTURE AWARD IS DR. LEWIS KULLER. WE'RE FORTUNATE, INDEED, THAT HE IS HERE WITH US TO GIVE THIS PRESENTATION ON THE OBESITY EPIDEMIC: WHY HAVE WE FAIL FPD DR. CULL SLER THE DISTINGUISHED UNIVERSITY PROFESSOR AFTER OF PUBLIC HEALTH AT THE UNIVERSITY OF PITTSBURGH. OBTAINED HIS M.D. AT GEORGE WASHINGTON UNIVERSITY HERE IN D.C. AND THEN THE MASTERS AND DOCTOR OF HEALTH AT JOHNS HOPKINS. HE WAS FOR TIME ON THE FACULTY SIMULTANEOUSLY AT JOHNS HOPKINS AND THE UNIVERSITY OF MARYLAND BUT THEN MOVED TO THE UNIVERSITY OF PITTSBURGH WHERE HE HAS BEEN FOR MOST OF HIS SENIOR CAREER. AS PROFESSOR AND CHAIR AND THEN MORE RECENTLY AS DISTINGUISHED UNIVERSITY PROFESSOR. HE HAS DONE MUCH TO SERVE THE NIH, THANK YOU VERY MUCH SH LEWIS, IN TERMS OF MANY DIFFERENT PANELS THAT HE HAS SERVED ON AND COUNCILS, FOR INSTANCE, TO THE NATIONAL INSTITUTE OF AGING, AND HAS MADE SUBSTANTIAL CONTRIBUTIONS ACROSS THE FIELD OF EPIDEMIOLOGY INCLUDING THE AREA HE IS GOING TO TALK ABOUT TODAY. IT COULD HARDLY BE MORE TIMELY TO HAVE A FOCUS, TODAY, ON THE PROBLEM OF OBESITY. WE HAVE RECENTLY SEEN PREDICTIONS THAT THIS MAY BE THE FIRST GENERATION FOR CHILDREN WHO ARE BORN TODAY WILL LIVE LESS LONG THAN THEIR PARENTS OR THEIR GRANDPARENTS BECAUSE OF THE TOLE OBESITY IS TAKING ON OUR POPULATION IF WE DO NOT FIGURE IN HOW TO REIGN IT IN. THERE'S THE FIRST LADY'S EFFORT CALLED LET'S MOVE. IF YOU'VE ALREADY SEEN SOME OF THE PROMOTIONS ABOUT THE HBO SPECIAL THAT IS COMING FORWARD WITH FOUR HOUR-LONG SESSIONS DESCRIBING THE CAUSES AND THE POTENTIAL INTERVENTIONS FOR THE OBESITY EPIDEMIC, YOU WILL BE, I THINK, INTERESTED IN SEEING HOW THAT PLAYS OUT BECAUSE MUCH OF IT IS BASED UPON DATA GENERATED BY NIH RESEARCH. WE HAVE RESEARCH BUT WE HAVEN'T FIGURED OUT HOW TO TURN THIS AROUND. PERHAPS WE WILL HEAR SOMETHING TODAY FROM DR. KULLER ABOUT WHAT WE MIGHT DO TO TRY TO DO SOMETHING TO TURN THE TIDE IN WHAT OTHERWISE IS ONE OF THE GREATEST THREAT TO THE PUBLIC HEALTH OF OUR NATION. SO WITHOUT FURTHER ADO, PLEASE JOIN ME IN WELCOMING DR. LEWIS KULLER, THIS YEAR'S GOR DAN LECTURER. [APPLAUSE] GORDON LECTURER. [APPLAUSE] >> THANK YOU VERY MUCH, DR. COLLINS, AN THANK YOU ALL FOR COMING TO THIS LECTURE. IT'S QUITE NICE TO SEE SO MANY PEOPLE INTERESTED IN THIS TOPIC. EPIDEMIOLOGISTS HAVE TO TALK WITH SLIDES. THE SLIDES ARE ARE NOT THAT RELEVANT IN TERMS OF THE IMPORTANCE OF THE SUBJECT, BUT THEY HELP ME KEEP TRACK OF WHAT I'M TALKING ABOUT AND HELP YOU A LITTLE BIT IN TRYING TO UNDERSTAND THE KEYWORDS THAT I'LL BE SAYING TODAY, AND I HOPEFULLY MAKE IT POSSIBLE FOR MOST OF YOU TO UNDERSTAND WHAT I'M SAYING INCLUDING MYSELF. UH, THIS IS AS POINTED OUT A VERY IMPORTANT TOPIC, AND IF I LEAVE YOU WITH ONE MESSAGE I WOULD SAY, IT'S THE FACT THAT IN ALL OF THESE EPIDEMICS THAT WE HAVE, THE CHRONIC DISEASE EPIDEMICS, MUCH LIKE DR. GORDON REALLY STRESSED, IT'S IMPORTANT TO USE GOOD SOLID EPIDEMIOLOGICAL METHODOLOGY TO TRY AND UNDERSTAND THE EPIDEMIC AND THEN APPLY PREVENTATIVE TECHNIQUES. EPIDEMIOLOGY IS REALLY THE BASIC SCIENCE OF PREVENTIVE MEDICINE AND IT'S REALLY NOT A VERY EXCITING FIELD UNLESS YOU USE IT TO APPLY TO THE APPROACH TO PREVENTIVE MEDICINE. SO WITH THAT I'LL START AND HOPEFULLY YOU'LL UNDERSTAND. [LAUGHTER] OBESITY IS DEFINED AS EXCESS BODY FAT AND HAS BECOME INCREASINGLY PREVALENT DURING THE PAST PAST 30 YEARS IN THE UNITED STATES AND THE REST OF THE WORLD. OBESITY IS ASSOCIATED WITH EXCESS MORBIDITY AND MORE TALENT, ESPECIALLY CARDIOVASCULAR DISEASE, DIABETES AND CANCER. WE HAVE FAILED TO CONTROL THIS OBESITY EPIDEMIC IN THE UNITED STATES, OBESITY IS BECOMING ENDEM MIK ESPECIALLY IN LOWER ECONOMIC CLASSES, 200930% OF ADULTS WERE OBESE AND 17% OF CHILDREN. THE ABILITY TO STORE FAT WAS PROBABLY A PROTECTION AGAINST FAMINE. MANY OF THE DISEASES IN PAST CENTURIES WERE ASSOCIATED WITH LOW BODY WEIGHT AND HEIGHT SUCH AS TUBERCULOSIS AND OTHER INFECTION DISEASES. THERE WAS A PREVAILING BELIEF THAT HIGH FAT AND PROTEIN DIETS WOULD PROTECT AGAINST THESE DISEASES. IN THE 1950s AND EARLY 1960s, IMAGINE EPIDEMIC OF AMPHETAMINE USE OCCURRED AMONG UPPER SOCIAL CLASS WOMEN IN THE UNITED STATES MARRILY FAR COSMETIC EFFECT. IT WASLY SUPPORTED BY THE DRUG INDUSTRY AND MANY PHYSICIANS. IN 1967, 8 BILLION DOSES OF AMPHETAMINES WERE PRODUCED ACCOUNTING FOR 5% OF ALL PRESCRIPTIONS IN THE UNITED STATES. BY 19 # 0 IT HAS -- 1970, THE EFFECTS LED TO THEIR STRICT REGULATION. BODY FAT, AS YOU KNOW, DISTRIBUTION DISTRIBUTION VARIES BY AGE, SEX AND OBESITY. WOMEN HAVE MORE FAT THAN MEN. APPROXIMATELY 28% OF FAT FOR WOMEN VERSUS 15% FOR MEN. THE PERCENTAGE INCREASES WITH AGE. NON-HISPANIC BLACK WOMEN HAVE LESS PERCENTAGE OF BODY FAT THAN WHITE WOMEN AT SIMILAR LEVELS OF BODY SIZE. LET'S LOOK AT THE OBESITY EPIDEMIC IN RELATIONSHIP OF TIME PLACE AND PERSON. AS YOU KNOW, THERE'S BEEN A DRAMATIC INCREASE IN THE PREVALENCE OF OBESITY AMONG BOTH MEN AND WOMEN -- THIS SLIDE IS JUST FOR WOMEN SHOWING FROM 1960-1962, TO 1999-2008. THERE'S NO CHANGE -- RATHER AS MOST RECENT DATA SHOWS, THE EVIDENCE SUGGESTS THAT THE EPIDEMIC PERSISTENT AND IS NOW PERHAPS BECOME AS I SUGGESTED ENDEM MIK IN THE POPULATION. OBESETHE OBESITY HAS BECOME PERSISTENT IN YOUNG PEOPLE SHOWING THE CONTINUE RATES FROM 1999-2010. OES CITY HOW BECOME A SOCIO ECONOMIC DISORDER WITH MORE MARK DIFFERENCES FOR WOMEN THAN FOR MEN IN LEVELS OF OBESITY BY EDUCATIONAL LEVELS. IF YOU CAN SEE HERE QUITE CLEARLY THE DRAMATIC DIFFERENCE BETWEEN FOUR-YEAR DEGREE OR TO ONLY 24% VERSUS 36% -- I'M SORRY, VERSUS 41% FOR THOSE IN HIGH SCHOOL EDUCATION. THAT'S IMPORTANT TO RECOGNIZE AND ALSO FOR SEVERE OBESITY. OBESITY PREVALENCE IS ALSO MUCH HIGHER FOR NON-HISPANIC BLACKS. AGAIN, NOTING HERE. THIS ESPECIALLY TRUE FOR CLASS THREE OBESITY WITH BMIs OVER 40. THIS DATA SUGGESTS THAT IT MIGHT BE POSSIBLE TO MODIFY THE OBESITY EPIDEMIC BY UNDERSTANDING THE DETERMINANTS OF THE DIFFERENCES INTY BY EDUCATIONAL LEVELS AND SOCIO ECONOMIC STATUS. HOWEVER THE PREVALENCE OF OBESITY IS 25% AMONG COLLEGE-EDUCATED AND MUCH HIGHER THAN IN SOME OTHER COUNTRIES IN THE PAST. OBESITY PREVALENCE OF 25% MAY BE A REASONABLE GOAL IN THE UNITED STATES WITHOUT A FAMINE. OBESITY IS AN EXAMPLE OF A COMMON SOURCE EPIDEMIC. THE COMMON SOURCE EXCESS ENERGY INTAKE AND DECREASED ENERGY EXPENDITURE. UNFORTUNATELY, IT IS DIFFICULT TO MEASURE INTAKE FROM DIETARY SERVERS OR EXPENDITURE FROM RESTING METABOLIC RATE AND EXERCISE. THERE IS A VERY POOR CORRELATION BETWEEN ESTIMATED CALORIC INTAKE AND -- WHICH IN MEASURING PHYSICAL WATER INTAKE INCLUDING QUESTIONNAIRES, BUT IT'S DIFFICULT TO COLLECT THE CALORIC EXPENDITURE IN POPULATION STUDIES BECAUSE OF THE NEED TO INCLUDE MEASURES OF SIZE, MUSCLE MASS AND EFFICIENCY. THE CONTROL OF OBESITY EPIDEMIC REQUIRES A BETTER UNDERSTANDING OF THE EPIDEMIOLOGY AND THE PATHOPHYSIOLOGY OF OBESITY. CERTAIN FACTORS ARE ARE IMPORTANT. FIRST, AND I THINK THIS IS A MESSAGE THAT WAS GIVEN BY THE FIRST DIRECTOR OF THE NATIONAL HEART INSTITUTE AND THOSE OF US IN EPIDEMIOLOGY ESPECIALLY FROM THE ERA OF HOPKINS HAVE CARRIED IT FORWARD FOREVER -- IT IS BASICALLY IMPOSSIBLE TO CONTROL ANY DISEASE SUCCESSFULLY EXCEPT BY PREVENTION. SECOND, UNDERSTANDING THE DETERMINANTS OF THE EPIDEMIOLOGY OF DISEASE ARE CRITICAL; THE HOST T AGENT AND THE ENVIRONMENTAL INTERACTION. THIRD, EPIDEMICS OF CHRONIC DISEASES SUCH AS OBESITY ARE DUE TO CHANGES IN BEHAVIOR, THAT IS THE HOST, THE INTERACTION OF NEW AGENTS, AND TECHNOLOGY, AND THE CHANGES IN THE SOCIAL AND PHYSICAL ENVIRONMENT THAT SUPPORT THE EXPANSION AND DEVELOP THE EPIDEMIC IN A GENETICALLY-SUSCEPTIBLE POPULATION. FOURTH, OVERTIME, HUMANS ARE DESTINED TO BECOMING HEAVIER .GIFFEN AN AVAILABLE SUPPLY OF FOOD AND DECREASED LEVEL OF ENERGY EXPEND CHUR. EXPENDITURE. THE DEVELOPMENT OF THE MODERN OBESITY EPIDEMIC INCLUDES THE FOLLOWING: FIRST, THERE HAS AN AN INTRODUCTION OF NEW AND EXPANDED BEHAVIORAL LIFESTYLES INTO THE ENVIRONMENT. THE MOST POWERFUL FACTOR HAS PROBABLY BEEN THE CHANGE IN FAMILY STRUCTURE. MOST OF OUR CURRENT EPIDEMIC BEGINS IN THE UPPER SOCIAL CLASS IN THE BETTER EDUCATION. NEXT, POPULATIONS BECOME EXPOSED TO A NEW AGENT, OFTEN ASSOCIATED WITH NEW TECHNOLOGY. FOR EXAMPLE T CIGARETTE SMOKING EPIDEMIC WAS PRIMARY DUE TO THE DEVELOPMENT OF TECHNIQUES FOR MANUFACTURING CIGARETTES AND MATCHBOOKS AT THE TURN OF THE 20th CENTURY. THE DEVELOPMENT OF TECHNOLOGY TO MASS PRODUCE FAST FOODS, FOR EXAMPLE THE WORK OF CROCK AND LATER AT THE MCDONALD'S COMPANY WHICH HE RAN AND OTHERS HAVE PLAYED A KEY ROLE IN THE OES THETY EPIDEMIC. ONCE A NEW TECHNOLOGY OR AGENT IS INTRODUCE INTO THE POPULATION, ECONOMIC ADVANTAGES AND MASS MARKETS WILL DETERMINE THE SUCCESS OF THE SPREAD OF THE AGENT. FOOD, FOR EXAMPLE, BECAME A MAJOR REPLACEMENT CIGARETTE SMOKING AND ALCOHOL. OVERTIME, FOOD HAS BECOME OUR NUMBER ONE SOCIAL BEHAVIOR. EATING FOR MOST SPEEM NOT A THERAPEUTIC CHALLENGE IN SPITE OF THE FEWVIEW OF MANY OF MY PUBLIC HEALTH COLLEAGUES. THE NEW BEHAVIORAL LIFESTYLES, AGENTS, QUICKLY SPREADS ESPECIALLY TO THE LOWER SOCIO ECONOMIC CLASS AND LESS SUGGEST EDUCATED. WIDE SPREAD AVAILABILITY FOR FAST FOOD CHAINS AND CHEAP FOOD IS A FUNCTION OF THE COST ADVERTISING, APPARENT PSYCHOLOGICAL BENEFIT, AND AS I POINTED OUT, REPLACEMENT FOR OTHER ADVERSE BEHAVIORS. THERE IS A VERY IMPORTANT PATHOPHYSIOLOGICAL COMPONENT. THAT IS AN APPARENT LACK OF APPETITE SUPPRESSION FOR MANY IN THE POPULATION. IF, FOR EXAMPLE, WE HAD VERY STRONG APPETITE SUPPRESSION, THEN IT IS LIKELY THAT THE OBESITY EPIDEMIC WOULD BE LESS RAMPANT. RECOGNITION OF THE ADVERSE EFFECTS OF THE OBESITY IS FIRST RECOGNIZED IN THE BETTER-EDUCATED. THIS IS SIMILAR TO WHAT HAPPENED WITH THE CIGARETTE SMOKING EPIDEMIC. THERE IS A VERY SHARP REVERSAL OF THE SOCIO ECONOMIC DISTRIBUTION OF DISEASE. THE ADVERSE DEBEHAVIOR BECOMES STIGMATIZED. OBESITY LIMITS SOCIAL ACCEPTANCE AND JOB OPPORTUNITIES. THIS IS INTERESTING. THE ADVERSE BEHAVIOR THEN BECOMES A DISEASE OR AN ADDICTION, GENETIC DISORDER OR UNIQUE METABOLIC ABNORMALITY. YOU CAN SEE THAT WHAT HAPPENS TO THE EPIDEMIC AND THIS IS EXACTLY WHAT HAPPENS IF EVERY EPIDEMIC. IT CHANGES AND SUDDENLY BECOMES A DISEASE AND WE HAVE NEW BEHAVIORAL INTERVENTIONS, MEDICAL INTERVENTIONS BUT AT THE BOTTOM LINE WE HAVE NO CLINICAL TRIALS THAT REVERSE MORTALITY. WE STILL DON'T KNOW WHY PEOPLE EAT TOO MUCH OR DON'T EXERCISE. WE HAVE NO DRUG FOR THERAPY FOR OBESITY AND WE HAVE TWO THOUSAND SURGERI SURGERIES PER YEAR. THE ORIGINS OF OES THETY EPIDEMIC ARE OFTEN SUBMERGED BY A A FOCUS ON PATHOPHYSIOLOGY AND DESCRIPTIVE EPIDEMIOLOGY. THERE WAS A NATIONAL PICKUP PUBLIC HEALTH RESPONSE OFTEN BASED ON THE LIMITED EVIDENCE OF SPECIFIC INTERVENTIONS. THE MEDIATE NEED TO DO SOMETHING TO STOP THE EPIDEMIC HAS A HIGH PRIORITY, UNFORTUNATELY IT MAY TAKE YEARS OF TRIAL AND ERROR TO DEVELOP A GOOD STRATEGY BECAUSE OF LIMITED UNDERSTANDING OF THE DERMENT NANTS OF THE EPIDEMIC. OFTEN THE DETERMINANTS OF THE EP MIK ARE POLITICALLY UNACCEPTABLE. NUMEROUS COMMITTEES, ORGANIZATIONS AND SOCIETY ISSUE VOLUMES OF REPORTS ON SOLUTION TO EPIDEMIC. POSSIBLY SOME OF THESE COULD SERVE AS APPETITE SU P PRESANTS. THE SIMPLE RULE IS, IF YOU DON'T KNOW WHAT TO DO, ORGANIZE COMMITTEES, WORKSHOPS AND SPREAD THE PROBLEM. [LAUGHTER] NOW LOOK AT SOME OF THE MORE DETAILED ASPECTS OF THE DETERMINANTS OF WAETH GAIN. THE AMOUNT OF [INDISCERNIBLE] ENERGY EXPENDITURE PRIMARILY FOR FROM EXERCISE ARE THE KEY VARIABLES. THE MAJOR DETERMINANTS OF -- THE CORRELATION BETWEEN 4 HOUR RESTING METABOLIC RATE AND FAT-FREE MASS IS ABOUT 0.8. THERE'S A VERY HIGH CORRELATION BETWEEN FAT-FREE MASS AND BMI. IN CONTROLLED EXPERIMENTS -- THIS IS A BEAUTIFUL STUDY FROM LOUISIANA BY GEORGE BRAY -- ENERGY INIS LINEAR RELATED WITH CHANGE IN BODY FAT AND CHANGE IN LEAN BODY MASS. INDIVIDUALS GAIN WAIT BECAUSE THEY EAT MORE CALORIES. FAT PEOPLE DO NOT EAT MORE CALORIES IN SPITE OF WHAT SOME PEOPLE THINK. THERE WAS A DRAMATIC INCREASE OVER TIME IN CALORIC INTAKE PER DAY EVEN AFTER ADJUSTMENT FOR FOOD SUPPLY AND WASTE. THE UNITED STATES DEPARTMENT OF AGRICULTURE REPORTS THAT THE ESTIMATED DAILY CONSUMPTION OF CAKE HOUSE IN THE YEAR 2000 WAS 95% GREATER. THE INCREASE IN [INDISCERNIBLE] WAS DUE TO REFINED -- FAT 24%, SUGAR 23% FROM 1970-1985. NOT OBESE -- SORRY, NOT OBESE ADULTS [INDISCERNIBLE] INGEST ABOUT NINE UNTHOUSAND KAY CALLS PER YEAR. -- AN AVERAGE 20-POUND WEIGHT GAIN OVER THE AGE OF 20-55 REPRESENTS ONLY A VERY SMALL DAILY VARIATION OF INGESTED CALORIES, CERTAINLY NOT MEASURABLE BY ANY OF OUR STANDARD TECHNIQUES. THE AMOUNT OF SMALL DIFFERENCES BETWEEN ENERGY INTAKE AND EXPENDITURE OVERCAN RESULT IN A VERY MAJOR INCREASE IN BODY WEIGHT. FOR EXAMPLE, A WOMAN AGE 50-59 GAINS A ABOUT 25 POUNDS OVER 28 YEARS, ABOUT ONE-AND-A-HALF POUNDS A YEAR OR AN EXTRA 50-75 KAY CALLS PER DAY. IN ORDER TO MAINTAIN THIS EXCESS WEIGHT T CALORIC INTAKE WOULD HAVE TO INBY A370 CALORIES PER DAY. HIGH CALORIC INTAKE MUST BE MAIN INTANED AFTER GAINING WEIGHT TO MAINTAIN THE HIGH BMI. TANED AFTER GAINING WEIGHT TO MAINTAIN THE HIGH BMI.TANED AFTER GAINING WEIGHT TO MAINTAIN THE HIGH BMI. TANED AFTER GAINING WEIGHT TO MAINTAIN THE HIGH BMI.A TANED AFTER GAI NING GHTOAIAITHI B.NAN AERAINGGH BMI. TEDFT GNI EIT MNTN E GHMIAN AERAING EIT MNTNE GHMID TEGAINWEHT O ININHEIGBM A 10% WEIGHT LOSS WOULD REQUIRE A CONSTANT DECREASE OF 15-250 KAY CALLS PER DAY AND A 20% ABOUT 325-430 KAY CALLS PER DAY. FIRST, AS A WOMAN, LET'S SAY, LOSES WEIGHT, BOTH FAT AND NON-FAT TISSUES WOULD BE LOST AS WELL AS WATER. 3,500 KAY CALL REDUCTION IN DIET OVER A WEEK, 500 CALORIES PER DAY WOULD CAUSE ABOUT A ONE POUND WEIGHT REDUCTION IN FAT PER WEEK. FOLLOWING -- THE WEIGHT LOSS WILL PLATEAU FURTHER DECREASES IN KAY CALL. THIS IS A MAJOR PROBLEM IN WEIGHT LOSS PROGRAMS AS INDIVIDUAL --. THE SECOND BIG FACTOR IS ENERGY EXPENDITURE. WE ARE THE VICTIMS OF THE SUCCESSES OF THE PREVIOUS GENERATIONS IN DEVELOPING NEW TECHNOLOGIES THAT GREATLY REDUCE ENERGY EXPENDITURE AT WORK AND IN THE HOME. THIS IS A DUH STU DPRI 1800 FROM GREAT BRITAIN AND IT SHOWS THAT IN THE HIGHEST INTAKE GROUP T HIGHEST BMI OF 26 THE KAY CALL CON SUFRPS IS OVER ABOUT FIVE THOUSAND CALORIES AND THIS IS BECAUSE AS WE'LL SEE, THEIR ACTIVITY. THIS IS BECAUSE OF VERY HIGH LEVELS OF PHYSICAL ACTIVITY ON THE WORK. INTERESTING ON THE AVERAGE THESE INDIVIDUALS WERE SHORT. THE HIGHEST SI -- THE LOWEST SI OF THE BMI, 26, WAS ASSOCIATED ABOUT A FIVE FOOT, 11 INCH MAN, BUT THE MIDDLE RANGE IS ONLY ABO ABOUT FIVE FEET FOUR TO FIVE FEET FIVE. THE SHORTER AND THINNER INDIVIDUALS DIED AT AN EARLY AGE. THE CALORIC EXPENDITURE AND THE PARS IS THE RATE OVER THE BASE L METABOLIC RATE. THIS IS FOR A MAN IN THE 1800s IN THE SAME PERSON IN ENGLAND AND IT SHOWS IN INTAKE AND YOU CAN SEE THE NUMBER OF HOURS AND WHAT THEY DID. SHOWS TREMENDOUS AMOUNT OF PHYSICAL ACTIVITY REQUIRED IN THE 1800s FOR THESE INDIVIDUAL, FAR GREATER THAN THE PRESENT TIME. THUS, IN PAST GENERATIONS THERE WAS BOTH THE VERY HIGH CALORIC INTAKE IN RESPONSE TO A VERY SUBSTANTIAL ENERGY EXPENDITURE. SIMILAR DATA HAS BEEN COLLECTED IN THE UNITED STATES FROM POPULATIONS AROUND THE 1850s. FURTHERMORE T LOWEST LEVEL OF CALORIC INTAKE IN THESE POPULATIONS COULD PROBABLY NOT WORK AND HAD VERY HIGH MORTALITY AT YOUNGER AGES. OUR ENERGY EXPENDITURE IS LOW AND HAS NOT DECREASED VERY MUCH DURING THE OBESITY EP EPIDEMIC. EFFORTS TO INCREASE ENERGY EXPENDITURE FOR THE MOST PART ARE MINUSCULE COMPARED TO WHAT WE'VE SEEN IN PREVIOUS GENERATIONS. LET'S ARE REVIEW THE DETAILS OF THE OBESITY EPIDEMIC. MOST LIKELY, EITHER PARENTS OR SINGLE PARENT AT HOME WERE WORKING OUTSIDE OF THE HOME. THIS HAD A MAJOR IMPACT ON THE OBESITY EPIDEMIC IN A GENETICALLY-SUSCEPTIBLE POPULATION. THE CHANGES IN FAMILY STRUCTURE, EMPLOYMENT OUT OF THE HOME HAD THREE MAJOR IMPACTS AND A HAS RESULTED IN THE DECREASE OF MEALS AT HOME DUE TO LACK OF TIME. IT HAS POSITIVELY LEAD TO INCREASED FAMILY INCOME WHICH MADE IT POSSIBLE TO BUY GREATER AMOUNTS OF SNACK FOODS OUT OF THE HOME AND FAST FOODS AND INCREASE THE MARKET FOR FAST FOODS AND PROBABLY REDUCED CHILDREN, ADULTS LEISURE TIME OUT OF THE HOME. THIS IS THE REALITY OUT OF THE SITUATION, WE HAVE TO LIVE WITH THIS CHANGE AND MODIFY OUR PRECHTIVE PROGRAMS IN RELATIONSHIP TO THIS. CHANGES IN WORK -- OOPS, SORRY. OKAY. CHANGES IN WORK PATTERNS ARE A WELL-KNOWN TO EVERYBODY INCLUDING THE PERCENTAGE OF MOTHERS IN THE LABOR FORCE WITH CHILDREN OURND 18 AND WOMEN WORKING LONG HOURS. THAT'S SHOWN HERE IN THESE MARKED HERE AND THEN THE RED CHANGES HERE. THIS IS NOT UNIQUE IN THE UNITED STATES AND THEREFORE CANNOT BE THE SOLE EXPLANATION OF THE OBESITY EPIDEMIC. THIS COMPARES THE NUMBER OF MEN AND WOMEN WORKING, THE PERCENTAGE DIFFERENCE BETWEEN MEN AND WOMEN AND YOU CAN SEE HERE THE UNITED STATES BUT ALSO FRANCE AND ALSO IN JAPAN WHERE AGAIN THERE'S BIG DIFFERENCES AND SO THIS IS NOT THE EXPLANATION -- ALONE CANNOT EXPLAIN EPIDEMIC. OKAY. THE DECLINE IN CIGARETTE SMOKING AND ALCOHOL CONSUMPTION HAS PLAYEDPLAYED A VERY IMPORTANT ROLE. THERE'S A -- FOLLOWING SMOKING CESSATION. CERTAINLY WE DO NOT WANT TO HAVE ANOTHER SMOKING EPIDEMIC. FOOD IS OUR NUMBER ONE SOCIAL OUTLET. LET'S MEET FOR LUNCH OR COME TO A DINNER PARTY. THIS IS A NEW PHENOMENON OF THE PAST 20 OR 30 YEARS. THERE'S AN INCREASE IN THE CONSUMPTION OF FAST FOODS AND SNACKS AND CALORICALLY DENSE FOOD. HARVARD HAS ARGUED THAT THE INCREASE IN SNACKS ARE THE MAJOR DERMENTS OF THE OES THETY EPIDEMIC BASED ON THEIR ANALYSIS OF DATA FROM THE CONTINUING SURVEY OF FOOD. PRIMARY INCREASE WAS FROM SNACKS WHICH I MARKED HERE IN BOTH MEN AND WOMEN, WITH LITTLE CHANGE THEY CLAIM IN CALORIES FOR BREAKFAST LUNCH AND DINNER. THIS IS PICTURE FROM MCDONALD'S AND WE'RE ALL FAMILIAR WITH THIS. AT THIS PICTURE, WHICH IS VERY EARLY IN THE EPIDEMIC, MCDONALD HAMBURGERS WERE 15 CENTS AND THEY SOLD OVER A MILLION AND THERE HAS BEEN A MUCH GREATER SALE OF THIS OVER TIME. THE PERCENTAGE OF THE TOTAL DISPOSAL INCOME FOR FOOD HAS DROPPED DRAMATICALLY IN THE UNITED STATES BUT YOU'LL LOOK AT THE BOTTOM AS THE COST OF FOOD HAS DROPPED THERE'S STILL AN INCREASE IN THE COST OF FOOD OUT OF THE HOME. THIS IS DUE TO BETTER TECHNOLOGY, OBVIOUSLY. IN 20006 THE AMERICANS SPENT 48% OF THEIR FOOD DOLLARS ON FOOD OUTSIDE OF THE HOME IN COMPARISON TO ONLY 28%. THE ABILITY TO MANUFACTURE LARGE AMOUNTS OF CHEAP, HIGH CALORIC FAST FOOD, MUCH LIKE THE DEVELOPMENT OF THE MACHINES TO MAKE CIGARETTES IS A MAJOR FAK NOR THE OBESITY EPIDEMIC. WE ARE THE PRODUCT OF SUCCESSES OF PAST GENERATIONS. BASELINE FREQUENCY OF FAST FOOD AND THE CHANGES IN FAST FOOD IS STRIKINGLY RELATED TO THE WEIGHT GAIN IN THE YOUNG ADULTS. THIS POINT THIS IS OUT VERY NICELY. THE OUT MIGRATION FROM URBAN AREAS AND WORK ENVIRONMENT HAVE A ALSO HAD A GREAT EFFECT. TRANSPORT TO WORK IS BY CAR, TRUCK, ORPHAN VAN. VERY FEW WALK OR BIKE TO WORK. ALSO TIME TO AND FRO FROM WORK HAS INCREASED FOR MANY INDIVIDUALS WHICH REDUCES THE POTENTIAL PLEASE SURE TIME FOR PHYSICAL ACTIVITY. LEISURE TIME IS SCARCE AND VERY EXPENSIVE. PEOPLE SELECT THEIR ACTIVITIES CAREFULLY. SPORTS AND EXERCISE ONLY SKRIBT A VERY SMALL AMOUNT OF LEISURE TIME. LET'S LOOK AT THE RESEARCH AREAS. WHAT ARE THE RESEARCH RECOMMENDATIONS? WHAT SHOULD WE D B DOING? ONE OF THE MOST IMPORTANT RESEARCH QUESTIONS TO DECREASE THE EPIDEMIC? FIRST, MOST PEOPLE CANNOT MAINTAIN WEIGHT LOSS BY DIET OR CONTINUED HIGH LEVELS OF EXERCISE; WHY? THEY ARE GAINING WEIGHT UP TO AGE 50 OR 60. WE DO A POOR JOB OF PREVENTING WEIGHT GAIN. ARE THERE SPECIFIC NUTRIENTS INDEPENDENT OF CALORIC INTAKE THAT WOULD MODIFY EATING BEHAVIOR? WE HAVE NO DECENT DRUGS FOR THE TREATMENT OF OBESITY. MOST SUCCESSFUL TREATMENT HAS BECOME BARIATRIC SURGERY. WHY DO SOME PEOPLE MAINTAIN A LOW BODY WEIGHT AND GOOD HEALTH IN THE FACE OF THE OBESITY EPIDEMIC? IS THIS GENETIC? HOST SUSCEPTIBILITY? A MAJOR PROBLEM IN WEIGHT GAIN AND INABILITY TO LOSE WEIGHT IS THE LACK OF [INDISCERNIBLE] AFTER EATING RESULTING IN FURTHER FOOD INTAKE. THE CHANGES IN BODY FAT AND WEIGHT LOSS TRIGGER RESPONSES IN THE BRAIN THAT LEAD TO HUNGER AND DECREASED METABOLIC RATE. WEIGHT GAIN SHOULD LEAD TO OPPOSITE RESPONSES. JUST AN EXAMPLE OF THIS AND SO MANY OF YOU JUST TO SHOW YOU BUT BASICALLY THERE'S A -- THIS IS JUST A VERY SIMPLISTIC MODEL OF RELATIONSHIP BETWEEN THE BRAIN T FAT STORES T MUSCLE, ENERGY EXPENDITURE AND WHAT SHOULD BE HAPPENING AND THE HORMONES THAT SHOULD BE AFFECTING THESE RESULTS. UNFORTUNATELY T SYSTEM SOUNDS GREAT BUT IT'S NOT WORKING VERY WELL FOR US., T SYSTEM SOUNDS GREAT BUT IT'S NOT WORKING VERY WELL FOR US.T T SYSTEM SOUNDS GREAT BUT IT'S NOT WORKING VERY WELL FOR US.HE T SYSTEM SOUNDS GREAT BUT IT'S NOT RKG RYELFOUST ST SND RE B IS T RKG RY ELFOUST ST SND GRT T 'SOTORNGER WE F U TYSM UN GRT T 'SOTORNGER WE F UT ST SND GRT T 'SOTORNGER WE F U TYSM UN L R .TYSM UNVE GRT T 'SOTORNGER WE F UH SYEM OUS EABUIT N RNGERWE F U NDGRT T 'SO.T ST TBRNTEIN O EGATN TO BODY FAT CONTENT. AS WE INCREASE BODY FAT WE SHOULD LOSE THE DESIRE TO EAT, INCREASE ENERGY, LOSE THE WEIGHT; BUT IT DOESN'T WORK. THE SYSTEM IS DRIVEN TO THE POSITIVE ENERGY BALANCE WEIGHT GAIN. SHOWS YOU A LITTLE BIT OF THAT WHICH SHOWS THAT THIS IS THE GROUP IN THE BOTTOM WHEN YOU GAIN WEIGHT AND YOU START WEIGHT LOSS AND THIS IS NORMAL WEIGHT BUT IF YOU LOOK, THE DRIVING FORCE IS HERE ARE BAY SEC THINK FACTORS THAT CONTROL WEIGHT GAIN, WEIGHT GAIN RATHER THAN WEIGHT LOSS AND SO HERE WE'RE DRIVEN PRIMARILY IN THIS DIRECTION WHICH IS ESSENTIALLY TO WEIGHT GAIN. THIS COMPLEX PHYSIOLOGICAL SYSTEM, VERY SIMPLISTIC MODEL, BUT THE KEY POINT IS THAT THERE MAY BE A FEW KEY PLAYERS THAT WOULD MAKE THE DIFFERENCE. THERE ARE VARIETY OF HORMONES THAT ARE SEE CREATED BY THE THE G. VMENT TRACT WHICH DETERMINE INSULIN SECRETION AND METABOLISM ESPECIALLY IN RELATIONSHIP TO EATING BEHAVIOR. ALL RIGHT. CLINICAL TRIALS TO EVALUATE WEIGHT LOSS HAVE BEEN UNSCUFFLE IN THE LONG TERM ESPECIALLY IF WE USE RECOMMENDED 10% WEIGHT LOSS AS A GUIDELINE THP. THIS SLIDE SHOWS A VARIETY OF STUDY AND THE MIDDLE CURVE SHOWS THE AVERAGE OF WEIGHT LOSS OVER THE FIVE YEARS. IT'S ESTIMATED THAT OVER FIVE YEARS THE AVERAGE WEIGHT LOSS IN THESE GOOD TRIALS IS THREE THE TO FOUR KILOGRAMS OR 68 POUNDS. WOMAN'S STUDY, WHICH WE DID IN PITTSBURGH WAS A 48-PONT TRIAL. DOCUMENTED LIFESTYLE SPER VENGS HAD A 3.4 KILOGRAM WEIGHT LOSS AT 48 MONTHS. THIS WAS SIGNIFICANT BUT MUCH SMALLER THAN AT 6 MONTHS. THE PERCENTAGE OF WOMEN WHO LOST GREATER THAN 10% OF THEIR WEIGHT DROP FROM 47% TO ONLY 21% OF THE WOMEN AT 48 MONTHS. THE KEY DERMENT DETERMINANT NANT -- WOMEN WHO LOST LESS THAN 10 POUNDS AT SIX MONTHS WERE FOUR POUND ABOVE BASELINE AT 48 MONTHS. EATING -- CHANGES IN EATING FISH, EATING FRUITS AND VEGETABLES AND INCREASING ENERGY EXPENDITURE WERE SOME OF THE KEY FACTORS ASSOCIATED WITH OBTAINING WEIGHT LOSS. WEIGHT GAIN WAS FROM INCREASE DESERTS AND FRIED FOODS AND MEET AND CHEESE. NO DATA ON SNACKS. THESE ARE SIMILAR DATA TO OTHER STUDY. THE INTERVENTIONS WERE STOPPED OR REDUCED OVER TIME IN ALL OF THESE STUDIES WITH SUBSTANTIAL WEIGHT REGAIN. ONE KEY MESSAGE IS THAT BEHAVIORAL INTERVENTIONS ARE LIKE DRUG THERAPY FOR HYPER TENSION OR ELEVATED LIPIDS. MOST LIKELY, THEY MUST BE CONTINUED FOR THE LIFETIME OF THE INDIVIDUAL. THE NATIONAL WEIGHT LOSS REGISTRY IS AN INTERESTING PROJECT DEVELOPED BY DR. WING FOLLOWING A SAMPLE OF INDIVIDUAL WHO IS LOST GREATER THAN 30 POUNDS AND HAVE MAINTAINED WEIGHT LOSS FOR AT LEAST ONE YEAR. MOST HAD LOST WEIGHT ON THEIR OWN. SIMILARLY, DECREASES IN CALORIC INTAKE, INCREASES IN PHYSICAL ACTIVITY, INCREASE IN EATING BREAKFAST, CAREFULLY DAILY WEIGHING AND REDUCTION IN EATING OUT OF HOME ARE MAJOR FACTORS ASSOCIATED WITH SUCCESSFUL LONG-TERM WEIGHT LOSS. THE KEY FINDING HOWEVER IS THAT THE PARTICIPANT EVEN MANY YEARS AFTER WEIGHT LOSS MUST CONTINUE TO CAREFULLY MONITOR THEIR WEIGHT AND LIFESTYLES AND AREEN REGAINING WEIGHT AFTER MANY YEARS OF SUCCESS. THE SITUATION IS VERY DIFFERENT WHEN IT COMES TO BARIATRIC SURGERY AND THIS IS THE GASTRIC BY PASS GROUP OVER TEN YEARS. THIS IS FROM THE SWEDISH OBESITY STUDY. THEY REPORTED SUCCESSFUL WEIGHT LOSS OVER 10 YEARS FOLLOWING GASTRIC BYPASS SURGERY. THE SURGERY IS A UNIQUE SURGERY WITH BYPASSES PART OF THE STOMACH AND BASICALLY THE DUODENUM -- AND A PIECE OF THIS IS MISSING UP HERE -- AND SMALL INTESTINE. WE SHOWED YEARS AGO E THAT BARIATRIC SURGERY WAS ASSOCIATED WITH SUBSTANTIAL REDUCTION IN THE PREVALENCE OF DIABETES FROM PREOP TO POST OP FROM 65-13% IN THE USE OF THE ORAL DIABETIC DRUGS RIGHT HERE AND FROM 27-6% FOR INSULIN USE, IRRESPECTIVE OF THE DURATION OF DIABETES. FURTHER STUDY SHOW THAT THE DIABETES DISAPPEARS LONG BEFORE THE WEIGHT LOSS AND EVEN WITHOUT WEIGHT LOSS AFTER THE SURGERY. JUST MANIPULATION O OF THE GA TROE INTESTINAL TRACK RESULTS IN THE DISAPPEARANCE OF THE DIABETES. THIS IS A VERY IMPORTANT CLUE TO THE CONTROL OF BOTH THE OBESITY EPIDEMIC AND DIABETES. THERE WAS A REDUCTION IN CARDIOVASCULAR EVENTS IN THE SWEDISH OBESITY STUDY AS WELL BUT STRIKINGLY IT WAS UNRELATED TO THE WEIGHT LOSS IN THE TRIAL OR TO THE BMI AT THE BEGINNING OF THE TRIAL. LET LOOK AT GEN X A LITTLE BIT. WHY ARE SOME ABLE TO REMAIN THIN WHILE OTHERS BECOME OBESE? STUDIES SUGGEST THAT 40-70% OF INDIVIDUAL VARIATION OES CITY DUE TO GENETIC FACTORS. THERE'S A VERY HIGH CORRELATION OF OES THETY WITHIN FAMILIES. A FEW RARE MAJOR GENES HAVE BEEN IDENTIFIED THAT ACCOUNT FOR A VERY SMALL NUMBER OF SEVERE OBESITY, ESPECIALLY IN CHILDREN. RECENT GENETIC STUDIES HAVE FOCUSED ON VERY LARGE POPULATIONS USING GENOMIC-WIDE ASSOCIATION STUDIES. THESE VERY LARGE STUDIES INCLUDING OVER A HUNDRED THOUSAND INDIVIDUALS HAVE IDENTIFIED MAYBE EIGHT LOCI CONSISTENTLY RELATED TO OBESITY. MOST GENES RELATED TO OES THETY SO FAR HAD THEIR EFFECTS IN THE CENTRAL NERVOUS SYSTEM. UNFORTUNATELY, MOST OF THE IDENTIFIED [INDISCERNIBLE] MARKERS HAVE VERY SMALL EFFECTS ON BODY WEIGHT OR ON THE RISK OF OBESITY WITH RELATIVE ARE RISK FROM 1.1-1.4 RANGE. SPEAKMAN HAS APPROACHED EVOLVING [INDISCERNIBLE] SOMEWHAT DIFFERENTLY. HE NOTED THAT TWO MILLION YEARS AGO PREDATION WERE REMOVED AS A SIGNIFICANT FACTOR FOR THE PROMPT OF SOCIAL BEHAVIOR, WEAPONS AND FIRE. THE ABSENCE OF PREDATION LED TO CHANGE IN THE POPULATION DISTRIBUTION OF BODY FATNESS DUE TO RANDOM MUTATIONS AND DRIP. THESE RANDOM MUTATIONS FAVORED THE DEVELOPMENT OF OES THETY BECAUSE THINNER INDIVIDUALS WERE AT HIGHER RISK OF PREMATURE MORTALITY FROM VARIOUS INFECTION DISEASES, MALNUTRITION AND VERY THIN WOMEN DID NOT REPRODUCE. IT WAS SUGGESTED -- IT'S ALSO SUGGESTED THAT THE POPULATION THERE WERE INDIVIDUALS WHO STILL HAVE GENETIC CHARACTERISTIC WHICH LEAD THEM TO BE VERY LOW BODY WEIGHT. OVER TIME THERE HAVE BEEN MULTIPLE MUTATIONS IN MANY GENES THAT HAVE SHIFTED TO SET POINT SO THE SET POINT IS GRADUALLY MOVING HERE FROM THE AMBULANCE WHERE THE SET POINT IS PUSHING TOWARD HIGH BMIT SET POINT HAS BEEN GRADUALLY LOWERED. HUMANS HAVE -- GO ON, NOW -- HUMANS HAVE VERY LARGE BRAINS. HUMAN BABIES ARE FAT. SOME OF THE FATNESS IN HUMANS IS CERTAINLY BROWN FAT WHICH PROTECTS AGAINST THE COLD ENVIRONMENT LEAVING THE WOMB. HUMAN BABIES AT BIRTH HA HAVE THE MOST FATNESS BECAUSE THE HEAD SIZE IS SMALL AND THERE'S A NEED FOR HIGH ENERGY SUPPLY EARLY IN LIFE IN ORDER TO NORMALIZE BRAIN GROWTH. THERE'S SUBSTANTIAL POST NATAL BRAIN GROWTH. OUR LARGE BRAINS MAY HAVE BEEN THE EVOLUTIONARY PRESSURE TO INCREASED FATNESS AND ALSO BEEN ABLE TO PRODUCE AN ENVIRONMENT WHERE WE'RE ABLE TO ENHANCE AND SURVIVE GIVEN THE FACT THAT THERE'S PLENTY OF FOOD AVAILABLE. THERE MAY HAVE BEEN GENETIC SELECTION AGAINST BABIES -- THE HUMAN VEE BRAL CORTEX HAVE -- THE FRONT L LOBE ESPECIALLY HAS AN IMPORTANT ROLE IN EXECUTIVE FUNCTIONS, COMPLEX DECISION MAKING AND EMOTIONAL RESPONSES. DAMAGE IN UTERO OR EARLY IN LIFE DURING RAPID BRAIN GROWTH COULD HAVE A PRIVATE EFFECT ON FUTURE BEHAVIORS. THERE CONTINUES TO BE A PREVALENCE OF CHILDREN BORN SMALL [INDISCERNIBLE] AND WHO ARE EXPOESZED IN UTERO TO EARLY LIFE BRAIN DAMAGE THAT CONTRIBUTES TO OBESITY DURING HIELD HOOD AND ADULT LIFE. IN FACT, IT IS POSSIBLE THAT WE MAY HAVE LOST THE BATTLE EVEN BEFORE WE'VE STARTED. THIS IS AN INTERESTING STUDY WE'RE DOING PITTSBURGH OF PSYCHOLOGICAL AND BEHAVIORAL DEVELOPMENT OF CHILDREN, ESPECIALLY LOW-INCOME POPULATIONS. THERE'S A VERY HIGH PREVALENCE OF SEVERE OBESITY AMONG THESE YOUNG GIRL. 8.2% OF A FRO AMERICAN GIRLS ARE SEVERELY OBESE WITH BMI CLOSE TO 40. THIS IS A VERY SERIOUS PROBLEM IN A COMMUNITY LIKE PITTSBURGH WHERE WE HAVE EXCELLENT PEDIATRIC SERVICES T EFFORTS OF MANY INVESTIGATORS TO MODIFY THE OBESITY EPIDEMIC. THE GIRLS CALORIC IMPLAN INTAKE VERSUS ENERGY IS UP TO ONE THOUSAND CALORIES A DAY BECAUSE OF THEIR EXCESS WEIGHT. OTHER IMPORTANT GENETIC DERMENTS OF THIS RAPID SEVERE OBESITY IN CHILDREN, WE DON'T KNOW. OBESITY RATES VARY DRAMATICALLY AMONG COUNTRIES. OF CONSIDERABLE IMPORTANCE IF S THE LOW RATES OF OBESITY IN JAPAN AND FRANCE. WHETHER THE MAJOR DIFFERENCES IN THE JAPANESE DIET IS THE HIGH INTAKE OF OMEGA FATTY ACIDS FROM FISH. THEY ARE THE MAJOR FATTY ACIDS IN THE BRAIN. THERE'S A VERY HIGH INTAKE OF FLAVOR NOID IN THE JAPANESE DIET AND LESS BEEF CONSUMPTION. THE FRENCH DO NOT EAT A SO-CALLED MEED TRAIN YAN DIET. THE DIET IS DOMINATED BY HIGH FAT FOODS, RICH SAUCES AND CHEESE AND HIGH INTAKES OF OMEGA-3 FATTY ACIDS FROM SAUCES. IT MAY NOT BE RELATEDED TO WHAT THEY EAT BUT HOW THEY EATED IT. THEY CONSUME MOST OF THEIR FOODS AT MEAL TIMES SHARED WITH OTHERS. THEY SHARE MUCH MORE TIME EAT THARG MEALS AND THEY RARELY SMACK BETWEEN MEALS. THERE WERE TWO EATING STYLES WHAT WE CALL THE STABLES OF THE UNITED STATES WILL WHERE INDIVIDUALS EAT ANY TIME OF THE DAY AND THE ZOO FOR THE FRENCH WHERE THE INDIVIDUALS EAT ONLY AT SPECIFIC FEEDING TIMES. MAYBE THE UNITED STATES HAS TO GO ON A ZOO PROGRAM. [LAUGHTER] EAT WELL, WHAT DOES IT MEAN? FOR AMERICANS IT'S FOR THE HEALTH AND FOR THE FRENCH, THE IT'S FOR PLEASURE. THIRD GROUP IS VEGETARIANS AND AGAIN VEGETARIANS, ESPECIALLY DOWN HERE PURE VEGETARIANS HAVE EXTREMELY LOW BMI. THIS IS GENERATED INTEREST ABOUT WHETHER BEEF CONSUMPTION COULD PERHAPS BE A CONTRIBUTED TO THE OBESITY EPIDEMIC. BEEF CONSUMPTION INCREASED AFTER WORLD WAR II, BUT SINCE THEN IT HAS BEEN FLAT OR EVEN DECREASING. THEREFORE IT'S UNLIKELY THAT INCREASE IN BEEF CONSUMPTION IS THE CAUSE OF THE OBESITY EPIDEMIC. HOWEVER THE UNITED STATES COMPARE WITH JAPAN AND MANY OTHER COUNTRIES HAS EXTREMELY HIGH INTAKE OF BEEF WELL ABOVE WHAT HAS BEEN RECOMMENDED IN THE UNITED STATES, THUS THE HIGH LEVELS OF BEEF CONSUMPTION IN THE UNITED STATES MAY IN PART CONTRIBUTE TO THE OBESITY EPIDEMIC. FURTHER AN INTERESTING PHENOMENON IS THE CONSUMPTION OF BOTTLED WATER IN THE UNITED STATES. SINCE 1908 WE HAVE DRAMATICALLY INCREASED THE CONSUMPTION AND SOFT DRINKING. WE HAVE CONVINCED THE PUBLIC THAT DRINKING WATER OUT OF A TAP IS DANGEROUS TO YOUR HEALTH. THIS IS A LITTLE BIT COMPLEX SO I'LL POINT IT OUT THAT WE CONSUME ABOUT 465 CALORIES PER DAY FROM FLUIDSES IN THE UNITED STATES DIET. FURTHERMORE WE HAVE SWITCHED THE SUGARS FROM SUCROSE TO FRUCTOSE. DIFFERENCES IN METABOLISM BETWEEN FRUCTOSE AND GLUCOSE ARE STILL A LIVELY DEBATE. FRUCTOSE IS ALMOST COMPLETELY METABOLIZED IN THE LIVER AS IMPORTANT SOURCE OF FATTY ACIDS IN THE LIVER AND MAY CONTRIBUTE TO INCREASED [INDISCERNIBLE] AND INSULIN RESISTANCE. SIMILARLY CHANGES IN OUR DIET HAVE AFFECTED THE GUT BACTERIA IN MICE SIT POSSIBLE TO VARY THE RISK OF OBESITY IN RELATIONSHIP TO THE BACTERIA GLOR RA. IN FARM ANIMALS PROBIOTICS INTO THE FOOD CHAIN THEY MAY HAVE HAD AN EFFECT ON OUR GUT BACTERIA AND OBESITY EPIDEMIC. I'M GOING SAIL A LONG A LITTLE BIT HERE. I JUST WANT TO SHOW YOU, UH, WHAT I THINK IS [INDISCERNIBLE]. JUST GOING SKIP A COUPLE OF SLIDES BECAUSE OF TIME. OKAY. ONE OF THE INTERESTING AREAS, I THINK, TO LOOK AT -- I DIDN'T HAVE TIME TO SHOW THIS IN DETAIL IS WHAT WE CALL EP TOMIC FAT A ACCUMULATIONS. THIS LEADS TO INSULIN RESISTANCE, DIABETES AND INABILITY TO LOSE WEIGHT. THE EXCESS FAT TRIGLYCERIDES CAN BE STORED IN [INDISCERNIBLE] AND CARDIAC MUSCLE. THE AMOUNT OF FAT INCREASES WITH AGE IN MEN AND WOMEN. THERE ARE TWO FAT DEPOTS IN SKELETAL MUSCLES. THE AMOUNT OF INTERMUSCULAR FAT INCREASES WITH BOW'S THE PI. MRS. THAT'S POSITIVE ASSOCIATION BETWEEN INTERMUSCULAR FAT AND TYPE 2 DIABETES. IT'S POSSIBLE THAT'S WHAT'S HAPPENING HERE THAT AS WE STORE THE FAT IN OUR MUSCLE THIS MAY HAVE EFFECT ON MITE COUNTRY YAN FUNCTION AND LT MATELY LEAD BACK TO A FACT OF MUSCLE INEFFICIENCY AND USING ENERGY, INCREASED DEMAND FOR CALORIES AND WEIGHT REGAIN. THIS MAY BE ANOTHER CLUE TO WHAT'S HAPPENING. VERY QUICKLY, WHAT ARE THE OPTIONS NOW FOR THE PREVENT OF OES THETY? OBESITY. FIRST OF ALL THE STIGMA TIEIZATION OF -- WE SHOULD END THE STIGMA TIEIZATION OF OBESITY, THIS SHOULD BE STOPPED FOR CHILDREN. EATING IS AN IMPORTANT SOCIAL BEHAVIOR AND NOT A THERAPEUTIC TRIAL. PEOPLE ARE OBESE NOT BECAUSE THEY WANT TO BE BUT BECAUSE OF THE INTERACTION OF THE AGENTS T DIETS THE EXERCISE T ENVIRONMENT AND THEIR GENETIC SUSCEPTIBILITY. SECOND, PREVENTION OF EIGHT GAIN IN CHILDREN AND YOUNG ADULTS SHOULD CLEARLY HAVE THE HIGHEST PRIORITY. THIS REQUIRES A TOTAL APPROACH NOT PIECEMEAL. CHANGES IN SCHOOL NUTRITION OR POORLY DESIGNED PHYSICAL ACTIVITY PROGRAMS. WE NEED THE SAME SUCCESSFUL APPROACHES THAT REDUCE CHILDHOOD INFECTION DISEASES IN THE PAST; VERY GOOD PUBLIC HEALTH AND PREVENTATIVE MEDICINE WITH DOCUMENTED OBJECTIVE OUTCOMES, CAREFULLY CONTROLLED AND EVALUATED OVERTIME WITH HARD END POINTS. PREVENTION PROGRAMS MUST BE FOR THE WHOLE. THEIR EATING BEHAVIOR IS NOTED AND ESPECIALLY SNACK FOODS HAS BECOME OUR MOST IMPORTANT ROLE AND WE SHOULD FOCUS ON THIS AREA. REGULAR FOOD CONSUMPTION ESPECIALLY BREAKFAST DINNER AND EATING MEAL AT HOME ARE CRITICAL. FOURTH WE SHOULD INCREASE CONSUMPTION OF TAP WATER. THIS NEEDS TO BE A NATIONAL EFFORT TO USE TAP WATER AS A REPLACEMENT FOR BOTTLES DRINKS. BECAUSE OF TIME I'M GOING SKIP A LITTLE OF THIS. FIFTH WE NEED TO IMPROVE AND MODIFY THE PHYSICAL ACTIVITY PROGRAMS FOR CHILDREN AND ADULTS SO THAT THEY HAVE [INDISCERNIBLE] UTILITY, ARE INTERESTING AND ARE CONSISTENT WITH THE CAPABILITIES. WE SHOULD BE UPGRADING FACILITIES AND IMPROVING ACCESSIBILITY. IN NEW YORK CITY, IN THE 1950s, TEACHERS [INDISCERNIBLE] WERE PROVIDED FOR PHYSICAL ACTIVITY FROM KINDERGARTEN TO HIGH SCHOOL GRADUATION. A BOOK IN 1958 STATED THAT THE EDUCATION IN YOUNG PEOPLE WE REALLY MORE AND MORE THE VALUE OF PHYSICAL ACTIVITY IN THE SCHOOL CURRICULUM. THE PROGRAM WAS INTEGRATED IN SCHOOL CURRICULUM. THE PRIMARY PURPOSE WAS NOT HEALTH OR OBESITY PREVENTION, BUT RATHER THE BELIEF THAT TO BE SUCCESSFUL IN LIFE A STUDENT MUST DEVELOP SKILLS AND ENJOYMENT OF PHYSICAL ACTIVITIES. THESE SKILLS WERE LINKED TO THE ABILITIES AND INTERESTS OF THE STUDENTS TO TRY AND ENSURE CONTINUATION OVER TIME. UNFORTUNATELY, THIS ELITIST APPROACH WAS LOST IN THE NUMEROUS POLITICAL AND SOCIAL CHANGES IN EDUCATION. THE OBESITY EPIDEMIC IS A COMMON SOURCE EPIDEMIC AND THEREFORE IS IMPORTANT WITH INDUSTRY E TO DEAL WITH THIS COMMON SOURCE EPIDEMIC. MUST BE DONE AS AN ACTIVITY COLLABORATIVE APPROACH SIMILAR TO WHAT'S DONE IN EFFORTS TO REDUCE THE AMOUNTS OF CHOLESTEROL AND SATURATED FAT IN THE DIET LEADING TO SUBSTANTIAL DECREASE IN LEVELS. MAJOR EFFORT TO DEVELOP FOODS THAT WILL DECREASE THE APPETITE AND INCREASE THE [INDISCERNIBLE]. SUBSTANTIAL INCREASE IN OMEGA-3S IN THE DIET, PERHAPS, MAYBE TO ONE GRAM A DAY AS IN JAPAN, WITHOUT USE OF PILLS. THERE NEEDS TO BE A GOOD TRIAL, A TEST AT WHETHER FRUCTOSE IN DIET IS REALLY HAZARDOUS. WE ALSO NEED TO TEST WHETHER PLANT-BASED DIETS WILL CHANGE EATING BEHAVIORS IN THE LONG TERM. FINALLY WHAT DOESN'T WORK? MANY OF THE CURRENT ACTIVITIES THAT HAVE BEEN SUCCESSFUL AND YET CONTINUE TO BE UTILIZED NEVER BEEN SCIENTIFICALLY EVALUATED PRIOR TO WIDE SPREAD DISSEMINATION INCLUDING WEIGHT LOSS PROGRAMS HAVE MINIMAL LONG TERM E EFFECTS. WE SHOULD BE FOCUSING ONLY ON WELL-DESIGNED LONG TERM WEIGHT LOSS TRIALS WITH TESTABLE HYPOTHESIS. THERE HAS TO BE COMMITMENT TO LONG-TERM STUDIES OR WE SHOULDN'T BE DOING THEM AT ALL. NUTRITION EDUCATION AND PUTTING CALORIES ON THE MENUS HAS VERY SMALL OR LIMITED EFFECTS. MORE DIETARY INTERVENTION ALONE IN OBESE INDIVIDUALS WILL NOT REDUCE DIABETE ENOUGH EXCEPT IN THE SHORT TEM. WE SHOULD END THE PROCESS OF RESTRICTING JOBS OR CHANGING INSURANCE FOR OBESE PEOPLE. THIS IS WRONG AND DOESN'T HELP. NOTIFYING PARENTS THAT CHILDREN ARE OBESE ARE ONLY [INDISCERNIBLE] THREE YEARS. [LAUGHTER] FINALLY AND MOST IMPORTANT -- AND AISLE STOP HERE -- IS THAT DOING GOOD AND TRYING TO REDUCE THE OBESITY EPIDEMIC WITHOUT ANY EVIDENCE THAT THE PROGRAM OR PROGRAMS WILL HAVE ANY REAL POSITIVE BENEFITS IS NOT GOOD. WE HAVE CLEARLY DEMANDED WELL-DOCUMENTED CLINICAL TRIALS AND EFFECTIVENESS STUDIES BEFORE WE IMPLEMENT LARGE PUBLIC HEALTH PROGRAMS WHICH IN THE END ARE COSTLY AND HAVE LITTLE EFFECTS. SIMPLISTIC APPROACHES LIKE TRYING TO RAISE THE PRICE OF SUGAR RI DRINKS TO WIPE OUT THE OBESITY EPIDEMIC ARE MISTAKE AND COUNTER PRODUCTIVE. IT'S TIME TO END THE COMMITTEE ON HOW TO REDUCE EPIDEMIC. RATHER, WE SHOULD DEPEND ON GOOD SCIENTIFIC INVESTIGATION TRANSLATED INTO EFFECTIVE PROGRAMS. THANK YOU. [APPLAUSE] >> WE HAVE TIME FOR SOME QUESTIONS, SO PLEASE IF YOU HAVE A QUESTION, USE THE MIKE TONE PHONES SO THAT EASY TO LISTENING TO THE VIDEO CAST CAN HEAR THE QUESTION.ONE PHONES SO THAT EASY TO LISTENING TO THE VIDEO CAST CAN HEAR THE QUESTION.ONE PHONES SO THAT EASY TO LISTENING TO THE VIDEO CAST CAN HEAR THE QUESTION.ONE HOS TT SYOSTIN O E DECA C HR E OS TT SYO STIN STN.NEHE T GO E O E DCA HR E ESONON PHESO ATASTOISNI TOHEID CT NARH UEIOON PHEO AASTOISNI THEI CT N ARHE UEIOPO THVIO STANETHG QUTI.HE ESOHAEA TLIENG THVIO STANEATHNG QUTI.MROONHOS TT SYO RE EONNESOHAEA TY LIENG T VEOASCA HE T QSTN.S TT SYO RHUEIOMIOPNE CT N SOHAEA LIEG T VIO STAEAT QUTI.S O ATASTOISNI TTH ID CT N ARHE UEIO >>XCE . RE AIFIAESBO SWTERSHAPELEAKBY HEON >> ARTIFICIAL SWEETENERS IN RELATIONSHIP TO OBESITY? >> OR DO THEY HELP? DO THEY PROVIDE [INDISCERNIBLE]? >> THEY'RE A LITTLE PIECE OF A BIG PROBLEM AND THEY'RE NOT GOING SOLVE THE PROBLEM ALL BY THEMSELVES. SO JUST SAYING WE HAVE ARTIFICIAL SWEETENERS WILL WIPE OUT THE PROBLEM, IT WAS LIKE THE ERA A FEW YEARS AGO WHERE WE BASICALLY TRIED TO HAVE ALL THE FOODS LABELED LOW-FAT BUT BASICALLY HAD THE SAME NUMBER OF CALORIES; IT DIDN'T DO ANY GOOD. >> I HAVE A COMMENT IN THAT WE ONLY HAVE ONE DRUG CURRENTLY AVAILABLE FOR OBESITY AND YET WE TACK ABOUT OBESITY AND WE'RE VERY UPSET THAT WE ONLY GET A FEW KILO WEIGHT LOSS. WITH THE MEDICINE THERE WAS A TRIAL WITH FOUR-YEAR FOLLOW-UP WITH ONLY 2-AND-A-HALF KILO WEIGHT LOSS DIFFERENCE, IT WAS A 1/3 REDUCTION IN THE INCIDENCE IN DIABETES. I WANT YOUR OPINION ON WHAT IS THE GOAL OF TREATING OBESITY. IT'S NOT KOZ MEE SIS, I WOULD HOPE YOU'D AGREE THAT PRESUME COMBLI IT'S BETTER HEALTH AND HERE WE HAVE A CONCRETE EXAMPLE WITH A FOUR-YEAR FOLLOW UP THAT ONLY TWO-AND-A-HALF KILOS REDUCTION IS OF BENEFIT. >> I HAVE TWO COMMENTS ABOUT THAT AND I WANT TO BE [INDISCERNIBLE] ABOUT IT, BUT ONE, IF YOU LOOK AT THE DPP RESULTS OUT OVER TEN YEARS TO SEE WHAT'S HAPPENING THAT BASICALLY THERE'S VERY LITTLE CHANGE IN DIABETE AFTER THE FIRST PART OF THE STUDY BUT WHAT HAPPENS IS IF YOU START OUT WITH PEOPLE IN A STUDY WHERE THE DEFINITION OF DIABETES A BLOOD GLUCOSE OF 126 AND YOU START OUT WITH PEOPLE WITH BLOOD GLUCOSE OF 122, IT DOESN'T TAKE MUCH TO GET IT UP TO 126. I JUST WROTE A PAPER WHERE I BASICALLY THINK WE SHOULD ABANDON THIS IDEA OF STRICT LABEL OF DIABETES AT SOME BLOOD SUGAR LEVEL BUT TREAT IT LIKE CLOSET ROLL AS A CONTINUOUS LEVEL. HOW MUCH BLOOD GLUCOSE DOES IT LOWER AND HOW MUCH DOES THAT LOWER THE DISEASE STROKE. WE DON'T HAVE CLINICAL TRIALS TO SUGGEST THAT LITTLE BIT OF WEIGHT LOSS IS GOING TO HAVE EFFECT ON MAJOR CARDIOVASCULAR OR CANCER OUTCOME. IF IT DID, IT WOULD BE AMAZING BUT I DOUBT IT VERY MUCH. >> THE TRIAL SIZE WOULD HAVE TO BE HUGE. >> THANK YOU FOR COVERING ALL THIS ISSUES. LOOKS LIKE [INDISCERNIBLE] IS NOT WORKING. WE COULD SEE PART OF THE OUTCOMES FOR SOME OF THESE STUDIES BUT THERE IS NO WAY TO CONTROL THE BEHAVIOR TO KEEP THE FOOT AWAY FROM THE MOUTH. [LAUGHTER] SO IT IS NEUROBEHAVIORAL SYSTEM WHERE WE NEED A DIFFERENT APPROACH. ANY IDEA YOU MIGHT COME UP WITH? >> WELL, I THINK YOU'RE RIGHT. I THINK WE HAVE TO BASICALLY LOOK AT THIS AS A NEUROBEHAVIORAL PROBLEM GIVEN THE FACT THAT WE'RE NOT GOING TO GO BACK TO A LIFESTYLE OF THE DISTANT PAST OR START CHOPPING DOWN TREES TO PREVENT OBESITY, AND I THINK RIGHT NOW WE HAVE TO TRY AND WORK ON IMPROVING THE DIET IN RELATIONSHIP TO INCREASING SEW TIETY AND DECREASING APPETITE AFTER EATING FOODS BUT ALSO UNFORTUNATELY I THINK WE NEED ULTIMATELY NEED SOME DRUGS THAT WORK. >> THANK YOU. >> HI. DO YOU THINK THAT CHANGES IN AGRICULTURAL SUBSTIES COULD MAY A ROLE IN DECREASING OBESITY. I'M THINKING OF DECREASING DIS FOR [INDISCERNIBLE] AND INCREASES FOR VEJTDABLES AND FRUITS? >> NOW WE TALKED ABOUT THAT FOR UMP TEEN YEARS IN TERMS OF WHEN IT WAS RELATED TO CLOSET ROLL LEVELS AND TRYING TO LOWER BLOOD CREST ROLLS AND THINGS LIKE THAT. IT SOUNDS GOOD BUT UNFORTUNATELY IN OUR SOCIETY IT DOESN'T WORK VERY WELL, SO IT SOUNDS GOOD BUT IT'S EXTRAORDINARILY DIFFICULT TO IMPLEMENT. THE OTHER THING TO REMEMBER IS THAT ALL THESE EPIDEMICS MOVE DOWNWARD IN THE SOCIO ECONOMIC STRAIN AND THAT'S THE GROUP THAT'S HARDEST TO REACH WITH THESE CHANGES. IT'D BE NICE TO CHANGE FOOD PRODUCTION IN A POSITIVE WAY. I THINK THE IDEA IS TO GET RID OF SNACK FOODS AND GET PEOPLE TO STOP SNACKING WOULD PROBABLY HAVE THE BIGGEST EFFECT. EASIER SAID THAN DONE. >> WHAT ABOUT THE ENVIRONMENTAL POLLUTANTS POSED BY -- THEY DON'T REALLY KNOW WHY, BUT THEY THINK THAT THERE ARE SOME KIND OF ESTROGENS THAT ARE BEING EXUDED BY PLASTICS AND ALSO THE HORMONAL INGESTION OF FOOD THAT'S BEEN GIVEN ALL THESE ANTIBIOTICS AND HORMONES IN THIS COUNTRY. IT'S VERY HARD TO BELIEVE THAT THIS DOESN'T HAVE AN INFLUENCE. >> IT'S POSSIBLE BUT YOU TO REMEMBER THAT THE OBESITY EPIDEMIC HAS HAPPENED NOT ONLY IN THE UNITED STATES BUT IN AUSTRALIA, GREAT BRITAIN, CANADA, MANY COUNTRIES AROUND THE WORLD. SO WHATEVER YOU LINK TO THE OBESITY EPIDEMIC IN TOTALITY, YOU HAVE TO THEN TEST IT WHETHER THE SAME PHENOMENON EXISTS IN THESE OTHER COUNTRIES AND IN MOST CASES THEY DON'T. THE ONE COMMONALITY IN MOST OF THESE THINGS HAS BEEN THE INTRODUCTION OF FOOD PROCESSES AND THE REDUCED COST IN FOOD AND THE CHANGES IN FAMILY STRUCTURE. I THINK THE TECHNOLOGY AND THE CHANGES IN THE SOCIAL ENVIRONMENT ARE PROBABLY OVERWHELMING MANY OF THESE OTHER FACTORS WHICH COULD ALSO BE IMPORTANT. >> WELL WITH OCEAN [LOW AUDIO]. >> THANK UH YOU SO MUCH FOR A WONDERFUL TALK. WHAT DO WE DO WITH THE LOW INCOME OR UNDERPRIVILEGED POPULATIONS THAT ARE REALLY THE ONES THAT ARE SUFFERING THE MOST FROM THIS BECAUSE THEY CANNOT AFFORD TO HAVE FRUITS AND VEGETABLES AND HALE FOODS. THEY ALSO ARE FACING OTHER TYPES OF CHALLENGES. THEY DON'T NECESSARILY HAVE THE BEST ACCESS TO HEALTH CARE. WHAT EXACTLY CAN WORK IN THESE PARTICULAR POPULATIONS? >> THAT'S A GOOD QUESTION AND MY OWN -- I TREE TO GET THAT AT THE END. I REALLY THINK WE NEED TO GO BACK TO SOME OF THE TRADITIONAL PUBLIC HEALTH APPROACHES. WHEN I FIRST STARTED THE PUBLIC HEALTH DEPARTMENT, FOR EXAMPLE, IN PITTSBURGH HAD ABOUT 400 PUBLIC HEALTH NURSES AND THEY MADE CERTAIN THAT EVERY KID GOT IMMUNIZED AND ADEQUATE NUTRITION AND FOLLOW-UP AND CARE. IT DOESN'T EXIST ANYMORE. WE'VE GIVEN THAT UP AND I THINK UNFORTUNATELY WE MAY HAVE TO GO BACK TO SUCH A SYSTEM. WE'VE INSTITUTIONALIZED IT IN OUR MEDICAL CENTERS AND THE PROBLEM IS OUT IN THE COMMUNITY. >> SECOND THING, WHAT ABOUT THE ADDICTION DIMENSION OF THINGS? SO A LOT OF PEOPLE, I MEAN AS HAS ALREADY BEEN MENTIONED IN NEUROBEHAVIORAL SYSTEM THE IT'S HAS BEENTIVE EAT BUG ALSO THE FACT OF HOW EATING OR CONSUMING HIGH-SUGAR CONTENT BEVERAGES IS ADDICTIVE. >> AGAIN, I THINK THAT'S IMPORTANT BUT IF YOU LOOK AT THE TOTALITY EPIDEMIC IN DIFFERENT COUNTRY TARNSD WORLD, YOU GOT TO FOCUS ON THE COMMONALITY OF THE FACTORS. THAT'S PROBABLY AN IMPORTANT FACTOR, THOUGH, AS WELL. >> YES. WHEN I GO TO THE GROCERY STORE, HOW DO YOU FEEL ABOUT UNAVAILABILITY OF ANYTHING OTHER THAN PROCESSED FOODS? DOES THAT HAVE ANY EFFECT ON WEIGHT GAIN? >> OH, SURE IT DOES. THE FOODS ARE ALL PROCESSES AND THE HIGH CALORIC IS MAJOR EFFECT. THE GOVERNMENT'S TRYING TO PUSH THE IDEA OF EATING MORE FRUITS AND VEGETABLES AND LOW CALORIC FOODS, BUT IT'S A VERY, IT'S A MAJOR CHALLENGE. >> WONDERING IF I COULD GET YOUR COMMENT ON A COLLEGELATION THAT WE PUBLISHED A COUPLE OF YEARS AGO REGARDING THE FOOD SUPPLY AND FOOD WAIST TRENDS THAT HAVE OCCURRED IN THE U.S. SINCE THE 70s. ONE OF THE THINGS WE NOTICED WAS THAT FOOD WASTE HAS GONE UP BY ABOUT FIVE HUNDRED CALORIES PER DAY WHEREAS FOOD INTAKE HAS ONLY GONE UP BY ABOUT TWO HUNDRED TO THREE HUNDRED CALLIES WER DAY. OUR INTERPRETATION WAS THAT WE'RE PUSHING THE CALORIES INTO THE FOOD SYSTEM, WE ACTUALLY ONLY EAT A LITTLE BIT OF IT. MORE OF THAT EXCESS WENT IN THE TRASH. >> THAT'S PROBABLY TRUE. MY LUNCH TODAY SO YOU'RE PROBABLY CORRECT. [LAUGHTER] I THINK THAT'S VERY TRUE AND I THINK THAT'S TRUE BECAUSE OF THE FACT THAT WE EAT FAST AND EAT FAST FOODS AND WE DON'T SIT DOWN. AETDING ALL DAY LONG AND EATING HERE AND THERE AND THROWING AWAY AND STARTING ON SOMETHING ELSE. >> ONE MORE QUESTION. >> YOU MENTIONED EARLIER IN YOUR TALK HOW THERE IS A STRONG, UM, ASSOCIATION BETWEEN CHILDREN THAT ARE OBESE AND PARENTS THAT ARE OBESE AND UH YOU MENTIONED IT'S AN INTERPLAY OF ENVIRONMENTAL FACTORS AND THEN LATER YOU SAID THAT NUTRITION EDUCATION ISN'T EFFECTIVE AND THAT RAISING THE AWARENESS OF PARENTS ARE NOT EFFECTIVE. HOW WOULD YOU SUGGEST THAT WE APPROACH THE PROBLEMS OF OBESITY IN YOUNG CHILDREN THAT ARE ALREADY OBESE. >> I HOPE I DIDN'T SAY THAT. WHAT I SAID IS IT'S NOT A GOOD IDEA TO SOUND OUT OR SADDLE OUT ONLY THE FAT KIDS AS PART OF YOUR NUTRITION EDUCATION. NUTRITION EDUCATION SHOULD BE FOR EVERYONE AND SHOULD AIM TO THE ENTIRE POPULATION. IT DOESN'T DO GOOD TO JUST SEND A NOTE HOME TO THE MOTHER AND SAY YOU HAVE A FAT KID. THE MOTHER KNOWS THAT AND MAY BE OBESE AS WELL. AS OPPOSED TO NUTRITIONAL EDUCATION FOR EVERYONE AND WHICH I THINK WOULD HAVE A MUCH BIGGER EFFECT. >> JUST A FOLLOW-UP ON THAT. THERE'S BEEN A LOT OF STUDIES THAT HAVE SHOWN THAT PARENTS ARE NOT AWARE THAT THEIR CHILD IS OBESE. DO YOU THINK THERE'S ANY VALUE IN RAISING THAT AWARENESS? >> I WOULD BE SURPRISED THAT THE PARENTS DON'T REALIZE THE CHILD IS OBESE; I WOULD HAVE SURPRISED IF IT WOULD HAVE ANY EFFECT. I COULD BE WRONG. THERE'S NO EVIDENCE OR STUDIES THAT HAS ANY REAL EFFECT. YOU COULD THAT ON A GOOD STUDY AND FIND OUT WHAT HAPPENS BUT RIGHT NOW I THINK IT'S MOSTLY HEARSAY AND WE NEED SOLID SCIENTIFIC EVIDENCE THAT THESE THINGS WORK. >> THANKS. >> SO LAST QUESTION HERE AND I APOLOGIZE BAUDS WE'RE PASSED THE HOUR BUT I'M SURE OUR SPEAKER WILL STAY DOWN IN FRONT IF YOU WANT TO COME AND ASK OTHER QUESTIONS. I'M JUST SENSITIVE TO THE TIME. >> I REMEMBER BACK IN PITTSBURGH YOU ALWAYS PROMOTED THAT IF ONE COULD INSTITUTE POLICY CHANGE, THAT WAS GOING TO BE THE BEST WAY TO GET SOMETHING TO BE PUT IN PLACE, SO PREVENT CARS, I REMEMBER -- ACCIDENTS, I REMEMBER YOU SAYING REDUCE THE SPEED. IF YOU HAVE -- SCHOOL SITUATION. WOULD YOU RECOMMEND -- WHAT WOULD YOU RECOMMEND THE GREATEST EFFECT FOR AN INTERVENTION? WOULD BIT FOCUSSED ON TRYING TO IMPROVE PHYSICAL ACTIVITY? GETTING A HOLD OF THE MENU AND NUTRITION ENVIRONMENT IN SCHOOLS? IF YOU COULD ONLY REALLY CHANGE ONE ITEM OR ONE ITEM AT A TIME? >> I TRY TO -- MY OWN FEELING WOULD BE, WOULD BE ON PHYSICAL ACTIVITY AND I WOULD SAY THAT GO GET THE 1958 EDITION OF NEW YORK CITY BOARD OF HEALTH PROGRAM FOR EDUCATION OF PHYSICAL ACTIVITY FOR THE SCHOOL KIDS. THE IT'S FANTASTIC. I ALMOST TEMPTED TO PUT A NEW COVER ON IT, I THOUGHT THE FOUNDATION WOULD GIVE ME HUGE AMOUNTS OF MONEY. [LAUGHTER] THEN I FELT I'D BE IN BIG TROUBLE LATER ON. IT'S A FANTASTIC DOCUMENT. IT LAYS OUT THE PHYSICAL ACTIVITY PROGRAM BEGINNING IN KINDERGARTEN AND GOING ALL THE WAY THROUGH HIGH SCHOOL, LITERALLY, AND IN DETAIL, NOTHING TO DO WITH OBESITY OR HEALTH BUT JUST TO DO WITH THE SOCIAL DESIRABILITY OF PHYSICAL ACTIVITY AND DIFFERENT TYPES OF ACTIVITY. SO IT'S NOT WALKING AROUND THE BLOCK OR CLIMBING AND IT GOES ALL THE WAY FROM TEACHING KIDS HOW TO PLAY GOLF, TENNIS, SWIMMING, YOU NAME IT, AND IT'S ORIENTED, I THINK, BEAUTIFULLY. THAT'S WHAT WE NEED IN THE SCHOOL SYSTEM. I THINK THAT WOULD BE THE NUMBER ONE PRIORITY. >> THANK YOU. >> LET'S THANK OUR SPEAKER AGAIN. [APPLAUSE] >> THANK YOU.