Finding what works for weight in the workplace

Finding what works for weight in the workplace Existing data and future directions Andrew Brown, PhD 2019-02-08

Acknowledgments Some slides were inspired by or made in collaboration with numerous colleagues. They will be acknowledged throughout verbally, with citations, or on the slides. However, the content reflects my thoughts, and not necessarily these individuals, anyone else, or any organization. Disclosures In the last 12 months, Dr. Brown has received personal payments or paid travel from: American Society for Nutrition, Indiana University, Kentuckiana Health Collaborative, Rippe Lifestyle Institute, Inc. Dr. Brown s institution, Indiana University, has received funds to support his research or educational activities from: American Federation for Aging Research, Dairy Management, Inc., NIH, Oxford University Press, Sloan Foundation, and University of Alabama at Birmingham. Slides are available upon request: awb1@iu.edu

Outline 1. Obesity is complex, but we sometimes treat it simplistically 2. What works for obesity generally? 3. Barriers and opportunities for weight in the workplace

Obesity is complex, but we sometimes treat it simplistically

Initial BMI Category Men, kg/m 2 Annual Probability of Attaining 5% Reduction in Body Weight Annual Probability of Attaining Normal BMI, Estimate (95% CI) 30.0 34.9 1 in 12 1 in 210 (197, 225) 35.0 39.9 1 in 9 1 in 701 (619, 797) 40.0 44.9 1 in 8 1 in 1 290 (1023, 1651) 45.0 1 in 5 1 in 362 (300, 442) Women, kg/m 2 30.0 34.9 1 in 10 1 in 124 (118, 131) 35.0 39.9 1 in 9 1 in 430 (390, 475) 40.0 44.9 1 in 7 1 in 677 (599, 769) 45.0 1 in 6 1 in 608 (527, 704)

E.g., if the individual went from 35-39 down to 30-34, and subsequently increased to 35-39 again Data for subsequent changes in BMI category in participants who showed an initial decrease in BMI category for (a) women and (b) men United Kingdom, 2004 2014.

Obesity Grows from Complex, Adaptive Systems Social Psychology Individual Psychology Food Production Food Consumption Individual Physiology Individual Physical Activity Human Physiology Physical Activity Context Source: Vandenbroeck IP, Goossens J, Clemens M. 2007. Building the Obesity System Map.

Breakfast eating versus skipping Body weight BMI Lean/FFM Fat % Fat mass WC W:H ratio FMI SAD

Fruits and vegetables

"Eat your meals off smaller plates and bowls and you'll serve yourself about 10 percent less, which can add up to hundreds of calories less every day."

Plate size did not influence energy intake, meal composition, or palatability in normal weight women during a multi-itemed open buffet lunch. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5037070/ "Eat your meals off smaller plates and bowls and you'll serve yourself about 10 percent less, which can add up to hundreds of calories less every day."

Plate size did not influence energy intake, meal composition, or palatability in normal weight women during a multi-itemed open buffet lunch. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5037070/ Using a smaller dining plate does not suppress food intake from a buffet lunch meal in overweight, unrestrained women https://www.sciencedirect.com/science/article/pii/s0195666313002080 The results of the experiment suggest that the plate size had no significant effect on the total energy of the meal. https://www.ncbi.nlm.nih.gov/pubmed/25049139 Counter to widely held belief, the use of a smaller bowl did not reduce snack food intake. Public health recommendations advising the use of smaller dishware to reduce food consumption are premature, as this strategy may not be effective. https://www.ncbi.nlm.nih.gov/pubmed/25995049 "Eat your meals off smaller plates and bowls and you'll serve yourself about 10 percent less, which can add up to hundreds of calories less every day."

Plate size did not influence energy intake, meal composition, or palatability in normal weight women during a multi-itemed open buffet lunch. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5037070/ Using a smaller dining plate does not suppress food intake from a buffet lunch meal in overweight, unrestrained women Cherry picked contrary examples. Additional examples had some decreased intake and more without. "Eat your meals off smaller plates and bowls and you'll serve yourself about 10 percent less, which can add up to hundreds of calories less every day." https://www.sciencedirect.com/science/article/pii/s0195666313002080 The results of the experiment suggest that the plate size had no significant effect on the total energy of the meal. https://www.ncbi.nlm.nih.gov/pubmed/25049139 Counter to widely held belief, the use of a smaller bowl did not reduce snack food intake. Public health recommendations advising the use of smaller dishware to reduce food consumption are premature, as this strategy may not be effective. https://www.ncbi.nlm.nih.gov/pubmed/25995049

Plate size did not influence energy intake, meal composition, or palatability in normal weight women during a multi-itemed open buffet lunch. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5037070/ Using a smaller dining plate does not suppress food intake from a buffet lunch meal in overweight, unrestrained women Cherry picked contrary examples. Additional examples had some decreased intake and more without. "Eat your meals off smaller plates and bowls and you'll serve yourself about 10 percent less, which can add up to hundreds of calories less every day." https://www.sciencedirect.com/science/article/pii/s0195666313002080 The results of the experiment suggest that the plate size had no significant effect on the total energy of the meal. https://www.ncbi.nlm.nih.gov/pubmed/25049139 But! Counter to widely held belief, the use of a smaller bowl did not reduce snack food intake. Public health recommendations advising the use of smaller dishware to reduce food consumption are premature, as this strategy may not be effective. https://www.ncbi.nlm.nih.gov/pubmed/25995049 Where are the studies of WEIGHT?

Will small sustained changes in energy intake or expenditure produce large, long-term weight changes? Weight (lbs) 166 165 164 35 year old 165 lb male walking 1 mile/d ~100 kcal/d 163 162 161 160 159 158 3500 kcal rule 157 156 0 2 4 6 8 10 12 Month Weight Loss Predictor: http://www.pbrc.edu/research-and-faculty/calculators/weight-loss-predictor/

Will small sustained changes in energy intake or expenditure produce large, long-term weight changes? Weight (lbs) 166 165 164 Weight Loss Predictor 35 year old 165 lb male walking 1 mile/d ~100 kcal/d 163 162 161 160 159 158 3500 kcal rule 157 156 0 2 4 6 8 10 12 Month Weight Loss Predictor: http://www.pbrc.edu/research-and-faculty/calculators/weight-loss-predictor/

Will small sustained changes in energy intake or expenditure produce large, long-term weight changes? Weight (lbs) 166 165 164 Weight Loss Predictor 35 year old 165 lb male walking 1 mile/d ~100 kcal/d 163 162 161 160 159 In 10 years, he would weigh 61 lbs by the 3500 kcal rule 158 3500 kcal rule 157 156 0 2 4 6 8 10 12 Month Weight Loss Predictor: http://www.pbrc.edu/research-and-faculty/calculators/weight-loss-predictor/

Simple expectations of weight change doi:10.1177/2047487317752186 The mean difference in energy expenditure between sitting and standing was 0.15 kcal/min By substituting sitting with standing for 6 hours/day, a 65 kg person will expend an additional 54 kcal/day. Assuming no increase in energy intake, this difference in energy expenditure would be translated into the energy content of about 2.5 kg of body fat mass in 1 year.

An analogy To extend the obesity oedema analogy, addressing all forms of obesity simply with caloric restriction and exercise ( eat less and move more ) would be akin to addressing all forms of oedema simply with fluid restriction and diuretics.

What works for obesity generally?

High-intensity, comprehensive lifestyle intervention N Engl J Med 2017;376:254-66. DOI: 10.1056/NEJMra1514009 Adapted from Jensen, et al. 2013 AHA/ACC/TOS Guidelines

Some Medications for Weight Loss Name Orlistat Lorcaserin Liraglutide Phentermine-topiramate Naltrexone-bupropion Action Lipase inhibitor 5HT 2c receptor agonist GLP-1 agonist Norepinephrine-releasing agent; GABA receptor modulation Opioid antagonist; dopamine/norepinephrine reuptake inhibitor Side-effects depend on the drug and the patient. Pregnancy is a contraindication for all of them. Adapted from N Engl J Med 2017;376:254-66. DOI: 10.1056/NEJMra1514009

Some Common Surgical Procedures for Weight Loss DeMaria EJ. N Engl J Med 2007;356:2176-2183.

Comparing Weight Loss at One Year Lifestyle intervention Gastric band Roux-en-Y Gastric Bypass Vertical sleeve gastrectomy Roux-en-Y Gastric Bypass Adapted from N Engl J Med 2017;376:254-66. DOI: 10.1056/NEJMra1514009

Barriers and opportunities for weight in the workplace

Workplaces as opportunities for improvement Survey: ~25% obtained food at work ~ 1300 kcal/wk Limited dietary quality (pizza, soda, cookies, brownies)

Workplaces as opportunities for improvement Survey: ~25% obtained food at work ~ 1300 kcal/wk Limited dietary quality (pizza, soda, cookies, brownies) Pre-post: Less time sitting; more time standing Less lower back pain Walking time, physical activity, stairs, and productivity unchanged More stimulating, better lit and ventilated, but noisier and providing less storage.

Many Wellness Programs Have Little Impact on Obesity Controlled study finds no effect Spending, behaviors, health status, productivity unchanged Strong selection effect People who enroll are already healthy Source: Jones et al. NBER working paper 24229, 2018. Irrelevant to 83% of people with obesity Source: Kaplan et al. Obesity 26.1 (2018): 61-69 Cubicles, photograph Stephen Coles / flickr

Equivocal evidence: Room for hope? Design RCT RCT Cluster RCT Quasi-experimental Pre-post RCT Pre-post Pre-post RCT Pre-post Quasi-experimental Pre-post RCT RCT RCT Pre-post Cluster controlled Length 3 M 6 M 10 W 8 W 16 W 15 W 10 W 24 W 6 M 12 W 12 W 12 W 3 M 9 M 3 M 6 W 9 M

Intervention components: Guided group sessions Single sessions Website support networks Competitions Self-weighing (or self-reporting) Physical Activity at work Fruit and vegetable provision Heart-rate/activity monitors Dietary education and others

Which components are effective? Intervention components: Guided group sessions Single sessions Website support networks Competitions Self-weighing (or self-reporting) Physical Activity at work Fruit and vegetable provision Heart-rate/activity monitors Dietary education and others

Study 1: WHPP presence is only related to perceived controllability of overweight

Study 1: WHPP presence is only related to perceived controllability of overweight Study 2: Hence, when the focus does not lie on individual responsibility, people with a high BMI experience lower levels of weight stigma than people with a low BMI.

We can make progress without stigma Study 1: WHPP presence is only related to perceived controllability of overweight Study 2: Hence, when the focus does not lie on individual responsibility, people with a high BMI experience lower levels of weight stigma than people with a low BMI.

What to do in the absence of (compelling) evidence? The absence of evidence is not the evidence of absence. Carl Sagan, Cosmos

What to do in the absence of (compelling) evidence? When we do not have evidence: Be honest about the evidence for helping with weight. The absence of evidence is not the evidence of absence. Carl Sagan, Cosmos Still try promising programs, especially if they are known to be beneficial in other ways. Implement in a way that, at the end, we will have evidence.

Some Resources obesityandenergetics.org obesity.org nutrition.org https://www.niddk.nih.gov/health-information/weight-management/body-weight-planner

Finding what works for weight in the workplace Existing data and future directions Andrew Brown, PhD 2019-02-08

In-person classes on chronic disease management, weight management, tai chi, physical fitness, financial wellness, healthy workplace habits; a tobacco cessation hotline online, self-paced wellness challenge

https://www.nber.org/papers/w24229.pdf