1. My Most Provocative Recommendations to the USA Joint Commission on Sports Medicine and Science Philadelphia, PA February 27, 2001 Steven N. Blair Professor Arnold School of Public Health University of South Carolina

2. Disclosures Medical/Scientific Advisory Boards –Jenny Craig, Inc –Alere –Technogym –Cancer Foundation for Life –Santech –Clarity Project Research Funding –NIH –Body Media –Coca Cola –Department of Defense

3. Outline Activity/fitness, or obesity—which is most important? Misinformation about obesity and health Quackery and nostrums about diet and exercise What should we do –Discover the cause of the obesity epidemic –Expertise on the President’s Council on Fitness, Sports & Nutrition –Equal attention to diet and physical activity –K-12 education on behavioral change –Increase gasoline tax

4. Activity/fitness is far more important than fatness as a clinical or public health problem

5. Ranking of selected risk factors: 6 leading causes of death by income group, estimates for 2004 Percentage of total (total: 1.53 billion) World Health Organization. http://www.who.int/healthinfo/global_burden_disease/global_health_risks/en/index.htm

6. Physical Activity and CRF as Predictors of All- cause Mortality 31,818 men and 10,555 women 1492 deaths in men during average follow- up of 14.6 years, and 230 deaths in women during average follow- up of 12.8 years PA mortality trends not significant after adj for CRF CRF trends significant after adj for PA Phys Act CRF Lee DC, et al. BJSM; pub online April 23, 2010

7. All-cause MortalityCVD Mortality *adjusted for age, exam year, smoking, alcohol, & parental history Lee CD, Blair SN, & Jackson AS. Am J Clin Nurt 1999; 69:373-80 RR for All-cause and CVD Mortality in Fit and Unfit ACLS Men by Body Fat Categories Body Fat%

8. Adjusted RR for All-Cause Mortality by Fitness and BMI, ACLS Women Farrell et al. Obes Res. 2002; 10:417-423 *adj for age, exam year, smoking, & health status

9. CRF and %Body Fat on Mortality Risk in 13,155 Hypertensive Men * Adjusted for age, exam year, physically inactive, family history, smoking, alcohol, resting SBP and DBP, & diabetes and hypercholesterolemia

10. Outline Activity/fitness, or obesity—which is most important? Misinformation about obesity and health Quackery and nostrums about diet and exercise What should we do –Discover the cause of the obesity epidemic –Expertise on the President’s Council on Fitness, Sports & Nutrition –Equal attention to diet and physical activity –K-12 education on behavioral change –Increase gasoline tax

11. Uncritical, Unfounded, or Unusual Comments about Obesity and Health

12. JAMA Used Pages for This? Obesity in the National Football League. JAMA 2005; 293:1061-2 –Nearly all were overweight –More that 25% had Class 2 obesity In other words, NFL players are big

13. We must improve school lunches because American children eat 50% of their calories at school. Mrs. Obama February 2010

14. Which causes more deaths in the U.S.—smoking or obesity? ~40% of U.S. adults think obesity causes at least as many deaths as does smoking ~20% of U.S. adults think obesity causes more deaths than smoking The truth –Smoking causes ~440,000 deaths/year –Obesity causes ~110,000 deaths/year

15. Outline Activity/fitness, or obesity—which is most important? Misinformation about obesity and health Quackery and nostrums about diet and exercise What should we do –Discover the cause of the obesity epidemic –Expertise on the President’s Council on Fitness, Sports & Nutrition –Equal attention to diet and physical activity –K-12 education on behavioral change –Increase gasoline tax

17. Model in the Article 1.Sky Reach-15 reps each side 2.Speed Intervals-10 sec at a moderate pace then 20 seconds at a fast pace for a total of 2 minutes 3.Bench Push-ups-15 reps 4.Walking Lunge-2 minutes 5.Tree Back Rows-15 reps 6.Speed Intervals (same as #2) 7.Jump Pull-ups-15 reps 8.Speed Steps-up and down stairs for 2 minutes 9.Hanging Leg Raise-15 reps 10.Speed Intervals (same as #2)

18. Drop 12 Pounds this Month Lose 5 pounds the first week –Consume 1200 kcal/day –Do the 10 exercises/day (total of 40 min) Estimate her weight 100-110 pounds (~50 kg) Estimate the 40 min workout is an average increase of 4 times resting metabolic rate 1 MET=1 kcal/kg/hour –So, 4 x 50 X.66=132 kcal/workout Five pounds/week=calorie deficit of almost 16,000 calories Somehow the math doesn’t work

21. Outline Activity/fitness, or obesity—which is most important? Misinformation about obesity and health Quackery and nostrums about diet and exercise What should we do –Discover the cause of the obesity epidemic –Expertise on the President’s Council on Fitness, Sports & Nutrition –Equal attention to diet and physical activity –K-12 education on behavioral change –Increase gasoline tax

22. Causes of the Obesity Epidemic

23. It’s calories that count Energy In Energy Out BMR Thermic effect of food Media (TV,PC) Cars No heavy labour Exercise Portion size High-fat foods Energy dense Low-fiber Soft drinks Snack foods

24. Is the Average Total Daily Caloric Intake Increasing?

25. Trends in Energy Intake NHANES 1971-2000 Data sources –NHANES I—1971-1974 –NHANES II—1976-1980 –NHANES III—1988-1994 –NHANES—1999-2000 Surveys were representative samples of noninstitutionalized U.S. women and men aged 20 to 74 years Source: MMWR Feb 6, 2004

26. Trends in Energy Intake 1971 to 2000, Men, NHANES Kcal/day Source: MMWR Feb 6, 2004

27. Trends in Energy Intake 1971 to 2000, Women, NHANES Kcal/day Source: MMWR Feb 6, 2004

28. NHANES Survey Methods 1971-2000 NHANES I and NHANES II –24-hour dietary recall, Monday-Friday NHANES III and NHANES –24-hour dietary recall, Monday-Sunday Other changes in methodology included better probing techniques and better training of interviewers Other changes in dietary behavior included more meals eaten away from home and increasing portion sizes

29. Obesity Epidemic Caused by Eating too Much, Claims Academic Average caloric expenditure in 1980 –Women=950 kcal/day –Men=1380 kcal/day Average caloric intake is now 3,500 kcal/day “Over the past 25 years…there has been no change in our levels of physical activity” “there has been no change in energy expenditure” Article on British Science Festival in the September 16, 2010 Daily Telegraph

30. Outline Activity/fitness, or obesity—which is most important? Misinformation about obesity and health Quackery and nostrums about diet and exercise What should we do –Discover the cause of the obesity epidemic –Expertise on the President’s Council on Fitness, Sports & Nutrition –Equal attention to diet and physical activity –K-12 education on behavioral change –Increase gasoline tax

31. President’s Councils President’s Council of Economic Advisors –Chair, Austan Goalsbee, on leave from the Univ of Chicago Booth School of Business –Cecilia Rouse, Professor of Economics and Public Affairs, Princeton University President’s Council on Fitness, Sports & Nutrition –Co-Chair, Drew Brees, New Orleans Saints –Co-Chair, Dominique Dawes, Olympic gymnast

32. Outline Activity/fitness, or obesity—which is most important? Misinformation about obesity and health Quackery and nostrums about diet and exercise What should we do –Discover the cause of the obesity epidemic –Expertise on the President’s Council on Fitness, Sports & Nutrition –Equal attention to diet and physical activity –K-12 education on behavioral change –Increase gasoline tax

33. Liposuction can’t salvage Navy career-Washington Post, 1/31/11 Mick Kruger, 38 year old master-at-arms –Never failed a fitness test –Routinely scores ‘excellent’ on 1.5 mile run –Has run one marathon and done 3 others on in- line skates –Performance evaluations laud him for ‘superb military performance’ –6’ 4” tall and 240 pounds –Neck=16” and Waist=40.5 inches –Navy is dismissing him because he is too fat –Who would you rather have defending you against a bad guy? Mick or ….

34. Outline Activity/fitness, or obesity—which is most important? Misinformation about obesity and health Quackery and nostrums about diet and exercise What should we do –Expertise on the President’s Council on Fitness, Sports & Nutrition –Equal attention to diet and physical activity –K-12 education on behavioral change –Increase gasoline tax

35. Outline Activity/fitness, or obesity—which is most important? Misinformation about obesity and health Quackery and nostrums about diet and exercise What should we do –Expertise on the President’s Council on Fitness, Sports & Nutrition –Equal attention to diet and physical activity –K-12 education on behavioral change –Increase gasoline tax

36. Thank you for your attention, and for allowing me to express my provocative ideas