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Nonexercise activity thermogenesis: a way forward to treat the worldwide obesity epidemic

2012; Elsevier BV; Volume: 8; Issue: 5 Linguagem: Inglês

10.1016/j.soard.2012.08.001

1878-7533

Shelly McCrady-Spitzer, James A. Levine,

Diet and metabolism studies

Obesity is an epidemic with already catastrophic consequences [[1]James W.P. The epidemiology of obesity: the size of the problem.J Intern Med. 2008; 263: 336-352Crossref PubMed Scopus (545) Google Scholar]. When a doctor sees a patient with obesity, not only does the doctor need to be cognizant that obesity affects every organ system, but the doctor also needs to be aware that it affects the patient's self-perception [[2]Wang Y.C. Colditz G.A. Kuntz K.M. Forecasting the obesity epidemic in the aging U.S. population.Obesity (Silver Spring). 2007; 15: 2855-2865Crossref PubMed Scopus (129) Google Scholar]. Patients think about their obesity and the discrimination they experience because of it approximately 5 times every hour [3Sikorski C. Riedel C. Luppa M. et al.Perception of overweight and obesity from different angles: a qualitative study.Scand J Public Health. 2012; 40: 271-277Crossref PubMed Scopus (18) Google Scholar, 4O'Brien K.S. Latner J.D. Ebneter D. Hunter J.A. Obesity discrimination: the role of physical appearance, personal ideology, and anti-fat prejudice.Int J Obes (Lond) Epub. 2012 Apr 24; Google Scholar]. It is unfortunate, because it is the combination of the patient with, not only their inbuilt genetic makeup, but also the environment in which they find themselves [[5]Hill J.O. Wyatt H.R. Reed G.W. Peters J.C. Obesity and the environment: where do we go from here?.Science. 2003; 299: 853-855Crossref PubMed Scopus (1704) Google Scholar] that is preventing the patient from moving and has precipitated their obesity. Obesity not only results in the patient experiencing medical issues, discrimination, and negative feelings, the costs, to corporate America are staggering. Obesity alone raises annual per capita medical costs by $2741 (in 2005 dollars) [[6]Cawley J. Meyerhoefer C. The medical care costs of obesity: an instrumental variables approach.J Health Econ. 2012; 31: 219-230Crossref PubMed Scopus (989) Google Scholar]. However, a patient with obesity with multiple complications can cost a company $7000–$10,000 per person per year more than their lean counterpart [[7]Finkelstein E.A. Trogdon J.G. Cohen J.W. Dietz W. Annual medical spending attributable to obesity: payer-and service-specific estimates.Health Aff (Millwood). 2009; 28: w822-w831Crossref PubMed Scopus (2065) Google Scholar]. One and one half billion people have obesity [[1]James W.P. The epidemiology of obesity: the size of the problem.J Intern Med. 2008; 263: 336-352Crossref PubMed Scopus (545) Google Scholar]. One half of the children in Beijing are obese [[8]Levine J.A. Obesity in China: causes and solutions.Chin Med J (Engl). 2008; 121: 1043-1050Crossref PubMed Scopus (38) Google Scholar]. The rate of accentuation of obesity in India is so rapid that it has the capability of slowing its growing economy. The rapid increase in obesity is a global issue [[9]James P.T. Leach R. Kalamara E. Shayeghi M. The worldwide obesity epidemic.Obes Res. 2001; 9: 228S-233SCrossref PubMed Scopus (913) Google Scholar]. There is debate as to whether it is the chair or the knife and fork that has caused the increase in obesity rates. During the past 150 years, data from multiple studies have shown that food intake has remained relatively constant. The U.K. data have suggested that as the obesity rates doubled since the 1980s [[10]Smith G.D. Shipley M.J. Batty G.D. Morris J.N. Marmot M. Physical activity and cause-specific mortality in the Whitehall study.Public Health. 2000; 114: 308-315Crossref PubMed Scopus (146) Google Scholar], the caloric intake actually declined. However, concomitantly with that there has been a progressive and systematic decline in energy expenditure, first with urbanization and now with the computer and car revolutions. Obesity occurs in the persistence of positive energy balance, such that energy intake is consistently greater than energy expenditure. The National Health and Nutrition Examination Survey has shown that the combined effect of access to low-priced food, concomitantly with the inactive lifestyle, has resulted in sustained positive energy balance and obesity [[11]Ogden C.L. Carroll M.D. Curtin L.R. McDowell M.A. Tabak C.J. Flegal K.M. Prevalence of overweight and obesity in the United States, 1999–2004.JAMA. 2006; 295: 1549-1555Crossref PubMed Scopus (7454) Google Scholar]. With this realization, it becomes of great interest to examine the progressive decline in daily energy expenditure. Energy expenditure [[12]Ravussin E. Lillioja S. Anderson T.E. Christin L. Bogardus C. Determinants of 24-hour energy expenditure in man Methods and results using a respiratory chamber.J Clin Invest. 1986; 78: 1568-1578Crossref PubMed Scopus (944) Google Scholar] is composed of the basal metabolic rate, thermic effect of food, and physical activity. The basal metabolic rate accounts for approximately 60% of the total energy expenditure in a sedentary individual. Approximately 73% of the variance in basal metabolic rate is determined by body size, with the lean body mass positively correlated with the basal metabolic rate. Thermic effect of food accounts for about 11% of the total; this is the energy expenditure associated with the ingestion and absorption of food and its conversion into intermediary metabolites. The remainder of energy expenditure is physical activity. The energy expenditure associated with physical activity is either associated with purposeful exercise, accounting for 20% of Americans who participate regularly, or nonexercise activity thermogenesis (NEAT), the energy expenditure of everyday living [[13]Levine J.A. Nonexercise activity thermogenesis (NEAT): environment and biology.Am J Physiol Endocrinol Metab. 2004; 286: E675-E685Crossref PubMed Scopus (145) Google Scholar]. The energy expenditure of everyday living is of great interest, because the vast majority of individuals with obesity have no exercise activity thermogenesis; thus, their entire bout of activity-associated energy expenditure is NEAT. Data from the United Kingdom display the vast distribution in total daily energy expenditure across an industrialized population [[14]Black A.E. Coward W.A. Cole T.J. Prentice A.M. Human energy expenditure in affluent societies: an analysis of 574 doubly labelled water measurements.Eur J Clin Nutr. 1996; 50: 72-92PubMed Google Scholar]. Thus, if body size accounts for basal metabolic rate and the thermal effect of food are small, the only explanation for how an individual of similar body size can expend 2000 kcal/d more than another individual of similar body size is through the variability in their activity energy expenditure. Similar to the United States, most people in Britain do not use fitness centers [15Dunton G.F. Berrigan D. Ballard-Barbash R. Graubard B.I. Atienza A.A. Environmental influences on exercise intensity and duration in a U.S. time use study.Med Sci Sports Exerc. 2009; 41: 1698-1705Crossref PubMed Scopus (33) Google Scholar, 16Boriani F. Bocchiotti M.A. Guiot C. “Self-sustainable” gym clubs tackling obesity: “exercise” for “energy”.Exerc Sport Sci Rev. 2008; 36: 212Crossref PubMed Scopus (2) Google Scholar]. Most people do not exercise regularly; thus, the only way to explain why, across a population, some people can expend 2000 kcal/d more than other individuals of similar size is because their NEAT is so variable. How can NEAT vary by 2000 kcal/d between two individuals of similar size, both living in civilized countries? The answer is because work practices differ greatly between individuals, and leisure time activities also differ tremendously between individuals. If one studies, using calorimetry, the energy expenditure of work, one sees that a chair-bound job can be associated with a NEAT of 300 kcal/d [[14]Black A.E. Coward W.A. Cole T.J. Prentice A.M. Human energy expenditure in affluent societies: an analysis of 574 doubly labelled water measurements.Eur J Clin Nutr. 1996; 50: 72-92PubMed Google Scholar]. If one were to take, theoretically at least, a group of individuals working in a modern office and transfer them into an environment in which agriculture was the primary work-related endeavor, the energy expenditure theoretically associated with work would increase from 300 kcal/d of NEAT to 2300 kcal/d. Work is a tremendous driver of the energy we expend through nonexercise activity. The energy expenditure of leisure time activities also has great variance [17Fenton M. Battling America's epidemic of physical inactivity: building more walkable, livable communities.J Nutr Educ Behav. 2005; 37: S115-S120Abstract Full Text PDF PubMed Scopus (32) Google Scholar, 18Dunstan D.W. Barr E.L. Healy G.N. et al.Television viewing time and mortality: the Australian Diabetes, Obesity and Lifestyle Study (AusDiab).Circulation. 2010; 121: 384-391Crossref PubMed Scopus (606) Google Scholar, 19Chave S.P. Morris J.N. Moss S. Semmence A.M. Vigorous exercise in leisure time and the death rate: a study of male civil servants.J Epidemiol Community Health. 1978; 32: 239-243Crossref PubMed Scopus (49) Google Scholar]. An activity that many of us engage in for most of our days is gum chewing [[20]Levine J.A. Baukol P.A. Pavlidis Y. The energy expended chewing gum.N Engl J Med. 1999; 341: 2100Crossref PubMed Scopus (51) Google Scholar]. Such an activity is associated with an excursion of energy expenditure versus resting of about 20 kcal/hr. The point is not necessarily that one should chew gum all day, but to make the point that the trivial activities actually have a significant thermogenic effect [[21]Levine J.A. Schleusner S.J. Jensen M.D. Energy expenditure of nonexercise activity.Am J Clin Nutr. 2000; 72: 1451-1454Abstract Full Text Full Text PDF PubMed Scopus (260) Google Scholar]. When a person engages in multiple low-level activities throughout the day, this can aggregate to a significant amount of energy expended [[22]Crespo C.J. Keteyian S.J. Heath G.W. Sempos C.T. Leisure-time physical activity among US adults: results from the Third National Health and Nutrition Examination Survey.Arch Intern Med. 1996; 156: 93-98Crossref PubMed Google Scholar]. Conversely, there are NEAT activities that can be considered high-effect activities. These high-effect activities occur when an individual becomes upright. As soon as one starts to walk, even at 1 mile/hr, equivalent to “shopping speed,” a person doubles their metabolic rate [[23]Ainsworth B.E. Haskell W.L. Whitt M.C. et al.Compendium of physical activities: an update of activity codes and MET intensities.Med Sci Sports Exerc. 2000; 32: S498-S504Crossref PubMed Scopus (6412) Google Scholar]. At 2 mile/hr, which is equivalent to purposefully walking to a meeting, a person increases their metabolic rate by about 150–200 kcal/hr, depending on their size. Rushed walking, which is equivalent to racing to an airport gate, can triple one's metabolic rate above the basal level. Thus, what a person does in their leisure time can dramatically affect their total daily energy expenditure. For instance, a person could return from work at 5:00 pm in the evening and sit in front of the television until falling asleep at 11:00 pm at night. That entire evening of leisure activity would expend approximately 50 kcal. In contrast, a person could return from work at 5:00 pm in the evening and start raking leaves or paint the basement, and in so doing, expend 100–150 kcal/hr. For that evening of avid home redecoration, one would expend 500–600 kcal compared with sitting in front of the television for 50 kcal. It is that combined effect of what one does during one's day as an obligate job combined with what one chooses to do in the evening that can account for why 1 individual of similar size can burn 2000 kcal more through NEAT than another individual of similar size [[24]Lanningham-Foster L. Nysse L.J. Levine J.A. Labor saved, calories lost: the energetic impact of domestic labor-saving devices.Obes Res. 2003; 11: 1178-1181Crossref PubMed Scopus (110) Google Scholar]. If so much variability exists in NEAT, is that variability relevant to weight gain? In a previous research study, we studied a group of lean individuals and determined exactly how much energy each individual required to remain weight stable. Each individual was then overfed by an excess of 1000 kcal/d for 8 weeks [[25]Levine J.A. Eberhardt N.L. Jensen M.D. Role of nonexercise activity thermogenesis in resistance to fat gain in humans.Science. 1999; 283: 212-214Crossref PubMed Scopus (796) Google Scholar]. That degree of overfeeding was maintained for 8 weeks, resulting in each individual receiving 56,000 excess kcal for that period. Although the degree of overfeeding was the same for each participant, the variability in how much fat each person gained was great. As shown in other studies [[26]Bouchard C. Tremblay A. Després J.P. et al.The response to long-term overfeeding in identical twins.N Engl J Med. 1990; 322: 1477-1482Crossref PubMed Scopus (1025) Google Scholar], individuals appear to gain weight at variable levels, regardless of the amount of energy consumed in excess. Those people who store excess energy as body fat are those who do not activate their NEAT with overfeeding [[25]Levine J.A. Eberhardt N.L. Jensen M.D. Role of nonexercise activity thermogenesis in resistance to fat gain in humans.Science. 1999; 283: 212-214Crossref PubMed Scopus (796) Google Scholar]. Those who eat 56,000 kcal greater than their energy needs and do not gain body fat appear to expend it through NEAT. To understand the mechanism of NEAT activation, the experiment was repeated with different subjects by our laboratory [[27]Levine J.A. McCrady S.K. Lanningham-Foster L.M. Kane P.H. Foster R.C. Manohar C.U. The role of free-living daily walking in human weight gain and obesity.Diabetes. 2008; 57: 548-554Crossref PubMed Scopus (117) Google Scholar]. These results were reaffirmed. The reason, however, an individual can consume 56,000 kcal and not gain excess weight is because this individual intuitively begins to walk [[27]Levine J.A. McCrady S.K. Lanningham-Foster L.M. Kane P.H. Foster R.C. Manohar C.U. The role of free-living daily walking in human weight gain and obesity.Diabetes. 2008; 57: 548-554Crossref PubMed Scopus (117) Google Scholar]. As an individual is overfed an excess of 1000 kcal a day, they take it on themselves, without necessarily realizing it or joining the gym, to increase their walking. The median free-living velocity of walking is 1.1 mile/hr, and overfed individuals increase walking by ∼2.5 extra hours daily. Thus, individuals who do not respond with changes in NEAT to overfeeding gain excess body fat. Individuals who activate NEAT stay lean, even when they are overfed. Our next question was, are there drivers that stimulate the NEAT response? To address this, our laboratory conducted studies on rats in which putative chemicals were injected into the paraventricular nucleus of the hypothalamus [28Kiwaki K. Kotz C.M. Wang C. Lanningham-Foster L. Levine J.A. Orexin A (hypocretin 1) injected into hypothalamic paraventricular nucleus and spontaneous physical activity in rats.Am J Physiol Endocrinol Metab. 2003; 2: 2Google Scholar, 29Novak C.M. Kotz C.M. Levine J.A. Central orexin sensitivity, physical activity, and obesity in diet-induced obese and diet-resistant rats.Am J Physiol Endocrinol Metab. 2006; 290: E396-E403Crossref PubMed Scopus (98) Google Scholar]. The rats were then placed inside of a calorimetry chamber and their movements were monitored continuously in the X, Y, and Z axis, in all axes of movement. Similar studies have been conducted using numerous different chemicals that potentially drive NEAT. One chemical that became of particular interest to our laboratory was orexin, an arousal protein [28Kiwaki K. Kotz C.M. Wang C. Lanningham-Foster L. Levine J.A. Orexin A (hypocretin 1) injected into hypothalamic paraventricular nucleus and spontaneous physical activity in rats.Am J Physiol Endocrinol Metab. 2003; 2: 2Google Scholar, 29Novak C.M. Kotz C.M. Levine J.A. Central orexin sensitivity, physical activity, and obesity in diet-induced obese and diet-resistant rats.Am J Physiol Endocrinol Metab. 2006; 290: E396-E403Crossref PubMed Scopus (98) Google Scholar]. In 1 study, we compared rats that were inbred for leanness over multiple generations to those that were inbred for obesity [[29]Novak C.M. Kotz C.M. Levine J.A. Central orexin sensitivity, physical activity, and obesity in diet-induced obese and diet-resistant rats.Am J Physiol Endocrinol Metab. 2006; 290: E396-E403Crossref PubMed Scopus (98) Google Scholar]. Before the orexin injections, the baseline measurements of physical activity for the rats inbred for obesity showed they had lower NEAT than the rats inbred for leanness. Even more intriguing is that when progressive doses of orexin were injected, the response of the rats with obesity was far less than that of the lean rats injected with similar doses. The brains of the obese rats appeared to have a diminished responsiveness to the same dose of chemical as those rats inbred for leanness. Other neuromediators have also been similarly implicated in the integration of NEAT into energy balance [[30]Novak C.M. Zhang M. Levine J.A. Neuromedin U in the paraventricular and arcuate hypothalamic nuclei increases non-exercise activity thermogenesis.J Neuroendocrinol. 2006; 18: 594-601Crossref PubMed Scopus (36) Google Scholar]. If NEAT is variable, centrally regulated, and implicated in fat gain, is NEAT important in obesity? To understand the role of NEAT in daily living, our laboratory developed a physical activity monitoring system (PAMS) [31Levine J.A. Lanningham-Foster L.M. McCrady S.K. et al.Interindividual variation in posture allocation: possible role in human obesity.Science. 2005; 307: 584-586Crossref PubMed Scopus (555) Google Scholar, 32Levine J.A. Measurement of energy expenditure.Public Health Nutr. 2005; 8: 1123-1132Crossref PubMed Scopus (228) Google Scholar]. This system enables us to track all the movements and postures of free-living individuals. Using this system, we are able to ascertain body posture. When an individual is standing, the body posture sensors indicate a vertical/vertical position; when sitting, the sensors indicate a horizontal/vertical position, and when lying, the sensors indicate a horizontal/horizontal position. Because the motion sensors are associated with all the posture senses, PAMS allows for all movements of a person in a 24-hour period to be captured by the laboratory. In an analysis of the PAMS data from free-living individuals while they were awake, we examined every walk that a free-living person took. A walk was defined as a standing posture that involved movement for at least half a second. This analysis allowed for a unique glimpse into how individuals choose to move throughout their day. That study showed that most walks taken by free-living people were of short duration, with the average walk lasting <12 minutes [[27]Levine J.A. McCrady S.K. Lanningham-Foster L.M. Kane P.H. Foster R.C. Manohar C.U. The role of free-living daily walking in human weight gain and obesity.Diabetes. 2008; 57: 548-554Crossref PubMed Scopus (117) Google Scholar]. Similarly, the walks are of low velocity. Thus, the average walk of a person is about 1.1 mi/hr and lasts for just <12 minutes. Therefore, it is the sum of all the different walks that explains how 1 person can expend by walking 850 kcal/d more of NEAT than another person who is taking slightly shorter, slower walks. Our movements throughout the day might not therefore be purely volitional but might be underpinned by a deep biology that determines movement. Perhaps some people choose jobs as post office workers and others choose sedentary jobs. Such decisions might be driven by subtle brain mechanisms. An individual with obesity, living in the same environment as an individual with more NEAT, is reasonable 2.25 hr/d more than their lean counterpart [[33]McCrady S.K. Levine J.A. Sedentariness at work: how much do we really sit?.Obesity (Silver Spring). 2009; 17: 2103-2105Crossref PubMed Scopus (110) Google Scholar]. A lean individual, living in the same environment as a person with obesity, is exploiting opportunities to be up and walking for 2.25 hr/d [31Levine J.A. Lanningham-Foster L.M. McCrady S.K. et al.Interindividual variation in posture allocation: possible role in human obesity.Science. 2005; 307: 584-586Crossref PubMed Scopus (555) Google Scholar, 34Levine J.A. Miller J.M. The energy expenditure of using a “walk-and-work” desk for office workers with obesity.Br J Sports Med. 2007; 41: 558-561Crossref PubMed Scopus (162) Google Scholar]. Somehow subtle “be active” responses in the obesity-prone person might differ from those of lean-prone individuals whose brains are responding to the same signals differently. How can one take advantage of this information to help individuals with obesity who might want to lose weight? The first question is what are the maximum capabilities of the human to move? To address this question, we conducted similar studies using the PAMS technology in Jamaica [[35]Levine J.A. McCrady S.K. Boyne S. Smith J. Cargill K. Forrester T. Non-exercise physical activity in agricultural and urban people.Urban Stud. 2011; 48: 2417-2427Crossref PubMed Scopus (15) Google Scholar]. We were interested in individuals working in agriculture and individuals who had migrated into urban Kingston who now worked in offices. We found ambulation in the rural, lean Jamaican individuals to be twice as great as that of lean individuals living in Kingston or lean individuals living in the United States [[35]Levine J.A. McCrady S.K. Boyne S. Smith J. Cargill K. Forrester T. Non-exercise physical activity in agricultural and urban people.Urban Stud. 2011; 48: 2417-2427Crossref PubMed Scopus (15) Google Scholar]. Similarly, people who were lean, working in the agricultural communities in Jamaica were seated for one half the amount of time as lean Americans. Thus, people in the United States are capable of potentially moving twice as much. Thus, here is the putative therapeutic window, an opportunity to increase calorie expenditure 350–750 kcal or more daily—if only we can get people out of their chairs. To exploit this 350–750-kcal window, we started to examine how we might build high-volume, low-cost sensors that would be amenable to a wider audience. We took the Micro ElectroMechanical Systems accelerometer technology and integrated it into an MP3 player earpiece [[36]Manohar C. McCrady S. Pavlidis I.T. Levine J.A. An accelerometer-based earpiece to monitor and quantify physical activity.J Phys Act Health. 2009; 6 (2009): 781-789Crossref PubMed Scopus (11) Google Scholar]. We then took that technology and linked it with a cellular telephone, which would enable people to start competitively “gaming” with respect to physical activity [[37]Manohar C.U. McCrady S.K. Fujiki Y. Pavlidis I.T. Levine J.A. Evaluation of the accuracy of a triaxial accelerometer embedded into a cell phone platform for measuring physical activity.J Obes Weight Loss Ther. 2012; 1: 106Google Scholar]. Next, we built a standalone device for consumers to use throughout their day [[38]Manohar C.U. Koepp G.A. McCrady-Spitzer S.K. Levine J.A. A stand-alone accelerometer system for free-living individuals to measure and promote physical activity.Infant Child Adolesc Nutr. 2012; 4: 222-229Crossref Scopus (8) Google Scholar]. As all of this was being done, however, a significant advance occurred in the technology. Both the iPhone (Apple Computer, Cupertino, CA) and Smartphone platforms incorporated a 3-axis Micro ElectroMechanical Systems accelerometer. These accelerometers are inside cellular telephones to rotate the screen as the machine is rotated. Suddenly, we had a mass marketed technology that enabled daily physical activity to be measured. These technologies have been validated in the laboratory [[37]Manohar C.U. McCrady S.K. Fujiki Y. Pavlidis I.T. Levine J.A. Evaluation of the accuracy of a triaxial accelerometer embedded into a cell phone platform for measuring physical activity.J Obes Weight Loss Ther. 2012; 1: 106Google Scholar] with energy expenditure, and these devices are precise and accurate physical NEAT sensing devices. We deployed an application (App), and 28,000 users used it within 6 months [[37]Manohar C.U. McCrady S.K. Fujiki Y. Pavlidis I.T. Levine J.A. Evaluation of the accuracy of a triaxial accelerometer embedded into a cell phone platform for measuring physical activity.J Obes Weight Loss Ther. 2012; 1: 106Google Scholar], which provided data similar to that of Westerterp [[39]Westerterp K.R. Pattern and intensity of physical activity.Nature. 2001; 410: 539Crossref PubMed Scopus (198) Google Scholar] (Fig. 1). This demonstrated the feasibility of using accelerometers for population-wide assessment of energy expenditure. Once we had the capability of measuring NEAT and access to the behavioral techniques to promote it [40Blair S.N. LaMonte M.J. Nichaman M.Z. The evolution of physical activity recommendations: how much is enough?.Am J Clin Nutr. 2004; 79: 913S-920SAbstract Full Text Full Text PDF PubMed Google Scholar, 41DiPietro L. Kohl III, H.W. Barlow C.E. Blair S.N. Improvements in cardiorespiratory fitness attenuate age-related weight gain in healthy men and women: the aerobics center longitudinal study.Int J Obes Relat Metab Disord. 1998; 22: 55-62Crossref PubMed Scopus (86) Google Scholar, 42Heller S.R. Clarke P. Daly H. et al.Group education for obese patients with type 2 diabetes: greater success at less cost.Diabet Med. 1988; 5: 552-556Crossref PubMed Scopus (70) Google Scholar], we wanted to design environments that were permissive to movement. Our first office of the future was developed in 2005. It was a standard office space populated with treadmills, bicycles, and a walking track. A total of 304 people worked there temporarily. There were desks; however, they were least favorably positioned in the space. This environment heralded the concept of walk while you work. However, the treadmill desk was only a visual representation of the concept [34Levine J.A. Miller J.M. The energy expenditure of using a “walk-and-work” desk for office workers with obesity.Br J Sports Med. 2007; 41: 558-561Crossref PubMed Scopus (162) Google Scholar, 43Thompson W.G. Levine J.A. Productivity of transcriptionists using a treadmill desk.Works. 2011; 40: 473-477Crossref PubMed Scopus (48) Google Scholar]. A person does not need a treadmill desk to be active during the workday. A stepping device with the same technology integrated into it [[44]McAlpine D.A. Manohar C.U. McCrady S.K. Hensrud D. Levine J.A. An office-place stepping device to promote workplace physical activity.Br J Sports Med. 2007; 41: 903-907Crossref PubMed Scopus (62) Google Scholar] will also allow for increased physical activity while at work. It is placed under a desk and can be pulled out and used at will; for instance during a telephone call. The technology intergraded into the device can provide a daily printout of how many miles a person has stepped. This technology cost just under $50. Less expensive and ubiquitously successful is the lanyard worn around the neck, “Walk and Talk Meeting in Progress”[[34]Levine J.A. Miller J.M. The energy expenditure of using a “walk-and-work” desk for office workers with obesity.Br J Sports Med. 2007; 41: 558-561Crossref PubMed Scopus (162) Google Scholar]. In each company in which it has been deployed, a protocol is put in place such that employees know not to interrupt people who are conducting walking meetings. Other office elements include moving printers away from where things are printed from (this is rarely popular), moving trash cans further away, and having walking tracks laid out with floor tape. Importantly, each of these intervention elements has been validated in the laboratory and assessed for safety and utility by people with obesity. These interventions have therefore been validated and are accessible by most people. For instance, most people, regardless of weight, can complete a 30-minute walk-and-talk meeting and use a stepper during telephone calls. We have focused on designing, testing, and validating all-inclusive methods of promoting daily physical activity. Moreover, we have validated comprehensive programs to promote office-based health and optional weight loss by building laboratories inside office complexes [[45]Koepp G.A. Manohar C.U. McCrady-Spitzer S.K. Levine J.A. Scalable office-based health care.Health Serv Manage Res. 2011; 24: 69-74Crossref PubMed Scopus (2) Google Scholar]. Subjects generally reach their weight goals and fat mass decreases while the lean mass increases. Full-scale deployments, however, require the need, not only for behavioral scientists, but also lawyers, company economists, healthcare providers, information technology personnel, janitorial staff, and managers. Companies do not want wellness initiatives unless an entire plan is in place with respect to ensuring their productivity objectives are met. Having developed these approaches for adults in offices, it was straightforward to take them into schools [[46]Lanningham-Foster L. Foster R.C. McCrady S.K. et al.Changing the school environment to increase physical activity in children.Obesity (Silver Spring). 2008; 16: 1849-1853Crossref PubMed Scopus (73) Google Scholar]. We interviewed focus groups of 11-year-old children and asked them to design their own school. The students devised this school environment akin to a Socratic village-style living environment (Fig. 2). We found that children like to study in hockey nets—akin to fort-building behaviors. The students also devised and designed white boards, which weighed 1.5 kg; light enough for them to carry around the environment. The space was decorated by their artwork, which was suspended from the ceiling. We used a number of mobile electronic technologies, wheeled desks, and pre-existing toys, such as the Dance Dance Revolution [47Lanningham-Foster L. Jensen T.B. Foster R.C. et al.Energy expenditure of sedentary screen time compared with active screen time for children.Pediatrics. 2006; 118: e1831-e1835Crossref PubMed Scopus (269) Google Scholar, 48Lanningham-Foster L. Foster R.C. McCrady S.K. Jensen T.B. Mitre N. Levine J.A. Activity-promoting video games and increased energy expenditure.J Pediatr. 2009; 154: 819-823Abstract Full Text Full Text PDF PubMed Scopus (200) Google Scholar]. Interestingly, a hierarchical development occurred in which the students became group advocates for their own health. We have had success with students taking on specific roles in a class-based health environment. Students also became proactive advocates beyond the classroom. One boy, for instance, wrote and met with leadership from a major cereal company to address the amount of sugar in children's cereals. One girl designed a desk that was converted into a commercial prototype. We examined the effect of the redesigned school using validated physical activity sensors. The students in the redesigned school moved twice as much as those in a traditional classroom [[49]Koepp G.A. Snedden B.J. Flynn L. Puccinelli D. Huntsman B. Levine J.A. Feasibility analysis of standing desks for sixth graders.Infant Child Adolesc Nutr. 2012; 4: 89-92Crossref Scopus (36) Google Scholar]. In another classroom in Idaho Falls, the entire classroom was redesigned and mobile desks and measurement matrices were put in place by a student's mother—community-based participatory research. In this example, the entire process was internally driven and successful. As school-based activity and nutrition programs expanded, it proved to be a challenge to validate these programs using robust measures. Thus, we built a bus containing a dual-energy x-ray absorptiometry scanner and a host of activity sensors and educational materials (Fig. 3). Thus, we can drive the laboratory to assess any given program's efficacy. However, the most important metric for school-based health programs is often educational attainment (similar to the productivity in offices). In schools that engage in active learning programs, educational attainment has improved. The human being was designed over 2.5 million years to walk. It was a feat of glorious engineering. Within a miniscule, in genetic terms, period, a mere 200 years, humans have been compressed into chairs. It is an unnatural position for this version of Homo sapiens. Sitting is an unhealthy way of spending our days, and, simply put, we are not designed to do it. There is a calling, to raise the sedentary from their chairs and let good health abound.