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  1. 1. FANUS Conference Abuja, Nigeria 2011The Obesity EpidemicPilar Riobo , MD, PhDMadrid , Spain
  2. 2. Today discussion points• Prevalence and Metabolic Syndrome• Causes of obesity – Excessive Caloric intake – Psychological factors (binge eating, nocturnal eating synd) – Social factors:  Excesive TV watching and videogames  Family meals protective  No breastfeeding  Short sleep duration  Light during night time  Friends and environment – Female obesity – Communication oportunities in nutrition
  3. 3. The Rising Rate ofChildhoodObesity is Alarming 30% of children are overweight or at risk for overweight
  4. 4. Obesity Today: Future Impact “Because of increasing rates of obesity…we may see the first generation that will be less healthy and have a shorter life expectancy than their parents.” Surgeon General Richard Carmona
  5. 5. Prevalence of obesity in children in granada, spain González Jiménez, et al. Nutr Hosp 2011
  6. 6. ALADINO STUDY. SPAIN 6-10 years old children
  7. 7. Prevalence of overweight and obesity in European countries Where is the mediterranean diet?
  8. 8. Relation between BMI and chronic diseases (NHS and PHS) Type 2 diabetes Cholelithiasis Hypertension Coronary heart disease Women Men 6 5Relative Risk 4 3 2 1 0 <21 22 23 24 25 26 27 28 29 30 <21 22 23 24 25 26 27 28 29 30 Body Mass Index (kg/m2) Body Mass Index (kg/m2) Willett WC, et al. N Engl J Med. 1999;341:427–434.
  9. 9. Obesity and overweight have been reported to beassociated with large decreases in life expectancy. Non-smoking women Smoking women Non-smoking men Smoking men Framingham Heart Study 13.7 Non-smoking women lost 7 years, 5.82 Non-smoking men 5.8 years 13.3 7.08 0 5 10 15 Implications of obesity at age 40 on life expectancy. Peeters, A, et al. Ann Int Med 2003;138:24-32.
  10. 10. Obesity is associated with increased risk for most cancers 1.44 Multiple myeloma (>35) 1.46 Colon & Rectum (>40)Type of Cancer (Highest BMI category) 1.51 Ovary (>35) 1.68 Liver (>35) 1.88 All Cancers (>40) 1.95 Non-Hodgkin’s Lymphoma (>35) 2.12 Breast (>40) 2.13 Gallbladder (>30) 2.51* All Other Cancers (>40) 2.64* Oesophagus (>30) 2.76 Pancreas (>40) 3.20 Cervix (>35) 4.75 Kidney (>40) 6.25 Uterus (>40) 0 1 2 3 4 5 6 7 8 9 10 11 Relative Risk of Death (95% Confidence Interval) Calle E et al. N Engl J Med 2003;348:1625-1638 Mortality from Cancer According to BMI >30->40 for U.S. Women in the Cancer Prevention Study II, 1982 through 1998
  11. 11. Risk of Alzheimer’s disease (AD) in elderly with and without metabolic syndrome 980 elderly subjects (337 male,622 female; 69-78) 13 cases AD in men 32 in women With metabolic syndrome Without metabolic syndrome 9 P<0.001Prevalence Alzheimers disease (%) 8 7 6 5 4 3 2 1 0 Women Men Vanhanen M, et al. Neurology 2006.67:843-47 Increased risk for cognitive dysfunction and dementia in elder women
  12. 12. Obesity and other risk factors Blood HDL-C PCRP pressure pro-thromboticT-Cholesterol-t OBESITY factors Insulín Diabetes Resistance TG,Lp(a) sdLDL
  13. 13. Hypertension and Obesity Direct and lineal relationship 20 25 30 35 40 IMCPrevalence10.6% (BMI<20), 13.3% (BMI 20-25), 22.8% (BMI 30-40) y 61.3% (BMI>40). Australian Longitudinal Study on Women’s Health Brown WJ et al. Int J Obes 1998;22:520-528.
  14. 14. Diabetes and Obesity 20 25 30 35 40 IMCBrown WJ et al. Int J Obes 1998;22:520-528.
  15. 15. ATP III Criteria for Identification of the Metabolic SyndromeAbdominal obesity (waist circumference) Men >102 cm Women >88 cmTriglycerides 150 mg/dLHDL cholesterol Men <40 mg/dL Women <50 mg/dLBlood pressure >130 / 85 mm HgFasting glucose >110 mg/dLDiagnosis of the metabolic syndrome is made when 3 or more of the risk determinants shown above are present.
  16. 16. How Common is the Metabolic Syndrome?• 24% all adults• 42% over age 60 yrs
  17. 17. But...., …individuals who are geneticallypredisposed to insulin resistance mayforestall or even prevent the developmentof diabetes by staying thin and physicallyactive.
  18. 18. What’s the Cause of Obesity?There is sometimes a tendency to focuson one specific CAUSE …. But……there’s no simple answer to thiscomplex issue…
  19. 19. The Biological Cause of Obesity is SimpleAn imbalance of calories IN and calories OUT! But…
  20. 20. …The Social Factors that lead to the Imbalance are Complex • Changing food habits due to busy lifestyles • Declining physical activity during work and leisure time • Changing physical environment (urban, safety) • Decreased sleep duration • Hedonic and reward aspects of food • Psychological problems • Side effects of common drugs
  21. 21. Weight Issues It’s Much More than ENERGY BALANCESocial factors play a role
  22. 22. Popularity of low-carb diets that 28blame carbohydrates and sugar for everything ?
  23. 23. Low-carb, high-protein, high-fat vs. conventional hypocaloric dietPRCT, 63 obese Low-carb lost more weight at 3 and 6 months but was similar at 12 months Foster GD et al. N Engl J Med 2003; 48:2082-2090
  24. 24. CARMEN Study .investigated the effects of replacing one-quarterof daily fat intake by complex or simple CHEnergy intake was ad libitum A low-fat, high-polysaccharide diet led to long-term moderate weight loss and improved serum cholesterol Increasing simple carbohydrates did not promote weight gainPoppitt S D et al. Am J Clin Nutr 2002;75:11-20
  25. 25. 18000 U.S. male physicians reported measures of breakfast, cereal intake, weight After13 years of follow-up,BMI and weight gain were inversely associated with intake of breakfast cereals, independently of other risk factors. Obes Res. 2005; 13:1952–1960
  26. 26. Fructose intake correlates closely with the rate of diabetes worldwideBray GA. Consumption of high-fructose corn syrup in beverages may play a role in the epidemic ofobesity. Am J Clin Nutr 2004; 79: 537-543.
  27. 27. Could Excessive Fructose Intake (>50 g/d) cause metabolic syndrome? The primary sources of fructose are table sugar (sucrose) and high fructose corn syrup. Unlike other sugars, the ingestion of excessive fructose induces features of metabolic syndrome in laboratory animals Fructose appears to mediate the metabolic syndrome in part by raising uric acid
  28. 28. Could Excessive Fructose Intake and Uric Acid Cause Type 2 Diabetes?
  29. 29. Fat makes us fat??Direct relationship between fat intake and weight: Higher caloric content/gram Difficult oxidation compared to carbs (Carbs are inmediatly oxidated) Higher palatability promotes increased consumption
  30. 30. Psychological problems severe depression in 32% suicidal risk in 23%. Anxiety : 50% Binge eating disorder (BED) : 1–4% of general population and about 30% of obese subjects attending weight control programs Night Eating Syndrome (NES) : morning anorexia, evening hyperphagia, and insomnia with awakenings followed by nocturnal food ingestion.Lester D. Depression and suicidality in obese patients. Psychol Rep.2011:108(2):367-8.
  31. 31. Psycohological problems at first visit assessment of patients at obesity clinic: • Elevated scores for depression in 48% • Elevated scores for anxiety in 56% • Personality trait overlapping with eating disorders in 22% • Elevated scores for bulimia in 11.5% • Significant impairment in quality of life in 30%A Tuthill et al. Q J Med, 2006: 9
  32. 32. Neurobiological mechanisms underlying food intake Brain dopamine, which regulates motivation for food intake, is likely to be involved Obese individuals overeat to compensate for a reward deficit Have fewer striatal D2 receptors and show less striatal response to palatable food intakeCoronal section showing less activation in the right caudate in the weight-gain group versus the weight- stable group during milkshake receipt–tasteless intake Stice E et al. J. Neurosci. 2010;30:13105-13109
  33. 33. Short sleep and sleep abnormalities 244 children, age 3 to 7. Each additional hour of sleep at ages 3-5 was associated with a reduction in BMI of 0.48 and a reduced risk of being overweight of 0.39
  34. 34. After 32 years follow-up, shorter childhood sleep times were significantly associated with higher adult BMI
  35. 35. The potential mechanisms through which short sleep duration could result in obesity. Taheri S Arch Dis Child 2006;91:881-884
  36. 36. Weight gain as side effect ofdrugs Anti-depresants and psychotropic Anti-histaminics Corticoids Beta-blockers Contraceptives ........
  37. 37. Antipsychotic drugsAfter a median of 11weeks treatment, weightincreased by: 8.5 kg with conventional antipsychotic drugs 6.1 kg with quetiapine 5.3 kg with risperidone 4.4 kg with aripiprazole Correl et al. JAMA, 2009;302:16 1765
  38. 38. Contraceptives Daily energy intake was higherand resting metabolic rate was lower in both follicular and luteal phases after medroxyprogesterone compared with placebo
  39. 39. Prolonged breast-feeding protects mothers from later-life obesity20 years after their last pregnancy,women who had breast-fed forless than 6 months had higher fat masspercentage, than mothers who hadbreast-fed for longer than 6 months But rates of breast feeding are low Wiklund P et al. Public Health Nutr. 2011;23:1-8
  40. 40. Frequency of Shared Family Mealssharing 3 or more family meals per week reduces odds overweight (12%), eating disorders (35%) Pediatrics 2011;127:e1565
  41. 41. Light at night increases body mass in mice • compared with mice in a standard light/dark cycle, • despite equivalent levels of caloric intake and total daily activity output. • Nocturnal rodents typically eat substantially more food at night Exposure to nighttime lighting and the resultingchanges in the daily pattern of food intake and activityalso may be contributing factors to obesity pandemic ?? Fonken LK. Proc Natl Acad Sci. 2010; 26:18664-9.
  42. 42. Activity Level and Risk of Overweight Professionals Health StudyMen watching 21 or more hours of TV per week were over 40% more likely to become overweight than were men viewing 1 hour per week Ching P. Am J Public Health 1996
  43. 43. The increased time spent in sedentary screen-basedactivities has also been implicated as contributing to overweight and obesity .
  44. 44. Television (TV) viewing:the dominant recreational pastime at all ages Higher TV viewing hours are associated - higher body mass index (BMI), - lower levels of fitness - higher blood cholesterol levels. Potential mediators of the effect: - less time for physical activity - reduced resting metabolic rate - increased energy intake (eating while watching TV and exposure to marketing of energy dense foods).
  45. 45. Children who watched the most television during childhood had the greatest increase in body fat over time By age 11, children who watched 3.0 h or more television per day had a mean sum of skinfolds higher (106.2mm, vs 76.5mm) than those who watched less than 2 per day
  46. 46. 70 children randomized to reduce their television viewing and computer use by 50% vs controlIn the intervention group, reductions in BMI and energy intake were shown Epstein. ARCH PEDIATR ADOLESC MED/ 2008
  47. 47. 70 children randomized to an intervention to reduce their television viewing and computer use by 50% vs controlReducing television viewing and computer use may have an important role in preventing childhood obesity In the intervention group, reductions in BMI and energy intake were shown Epstein. ARCH PEDIATR ADOLESC MED/ 2008
  48. 48. Effects of active video games on body composition a randomized controlled trial BMI from baseline, at 24 wk control group increased 0.34 intervention group reduction−0.24 change in BMI by ethnic subgroup]. Small but definite effect on BMI and body composition in overweight and obese children at 24 wk Maddison R et al. Am J Clin Nutr 2011;94:156-163
  49. 49. Friends Framingham Heart Study cohortAmong married couples, when an alter became obese, the spouse was 37% morelikely to become obese.If an ego stated that an alter was his friend, the ego’s chances of becoming obeseincrease by 57% if the alter became obese. Between mutual friends, the ego’s risk of obesity increased by 171%
  50. 50. Having obese social contacts might lead to adopt specific behaviorsCould obesity be considered contagious???
  51. 51. Female obesity rates of obesity are higher in Effects during women pregnancy on offspring Metabolic effects during pregnancyIn an obesogenic environment, women are at greater risk for obesity .Transgenerational issues: Nutrition during fetal and early life can influence riskfor obesity on offspring
  52. 52. Obesity and pregnancy Medical Complications Technical ComplicationsEarly Miscarriage Difficult ultrasoundpregnancy Twinning  pregnancy induced hypertension GDM occurs in ~4% of pregnancies  pre-eclampsiaAntenatal  gestational diabetes Overweight women have 17% risk  venous thromboembolism Higher rates for  induction of labor Operative: higher rates c-sectionIntrapartum  planned and acute c-section infection, bleeding and thrombosis  assisted delivery Anesthesia  vaginal tearsPostpartum Macrosomia, congenital Hemorrhage, infection, venous thromboembolismFetal abnormalities, fetal distress, Birth injury Macrosomia, morbidity and mortality perinatal congenital abnormalities, fetalFetal distress, perinatal morbidity and mortality Birth injury
  53. 53. Body Mass Index predicts infertility in women with and without PCOS 4.0 3.5 With PCOS 3.0Relative Risk 2.5 2.0 1.5 1.0 0.5 Without PCOS 0 <16 16-17.9 18-19.9 20-21.0 22-23.9 24-25.9 26-27.9 28-29.9 30-31.9 >32 35 BMI at Age 18 Adapted from Rich-Edwards JW, Goldman MB, Willett WC, et al. Am J Obstet Gynecol 1994;171:171-7
  54. 54. Diabetes epidemic 300 300 millions 250Millones de personas 200 135 millions 150 154 millionsio 100 50 0 1995 2000 2025 King H. Diabetes Care 1998
  55. 55. Increasing Prevalence of Diabetes from 1990 to 2000
  56. 56. Insulin Resistance: A Primary Factor in Type 2 Diabetes– Condition in which greater than normal amounts of insulin are required to produce a normal biological response Olefsky JM. In: Ellenberg and Rifkin’s Diabetes Mellitus. 5th ed. 1997:513-552.
  57. 57. Diabetes Mellitus Health Impact of the Disease 6th leading cause of death Renal Life expectancy failure* 5 to 10 yrBlindness* Cardiovascular Diabetes disease 2X to 4X Nerve damage in Amputation* 60% to 70% of patients*Diabetes is the no. 1 cause of renal failure, new cases of blindness, and nontraumatic amputations Diabetes Statistics. October 1995 (updated 1997). NIDDK publication NIH 96-3926. Harris MI. In: Diabetes in America. 2nd ed. 1995:1-13.
  58. 58. Decreased sleep duration or quality may increase diabetes risk Selective suppression of SWS, without any change in total sleep time, results in marked decreases in insulin sensitivity, leading to reduced glucose tolerance and increased diabetes riskTasali et al. Slow-wave sleep and the risk of type 2 diabetes in humans PNAS, 2008; 105 1044–1049
  59. 59. Diabetes prevention studies • Malmo Preventive Trial withDiet&Exercise • DaQuing IGT • Orlistat • SOS (Swedish Obese Subjects) • Finnish Diabetes Prevention • Diabetes Prevention Program • TRIPOD • STOP-NIDDM
  61. 61. But, changing habits is not easy
  62. 62. So, it’s critical that nutrition communicators help people and provide motivating tips so they can adopt more healthful habits
  63. 63. But consumers are confused about who and what tobelieve when it comes to nutrition …
  64. 64. Many people find itConsumers are difficult to separatebombarded with Web validnutrition Food Sites TV and recommendations Radioinformation from Labels News from fad diet advice.a variety ofsources. Popular Medical Magazines Consumer Experts Media Fad Diet Nutrition Images Gurus information is Friends and Food often seen as contradictory, Family Gov’t Guidelines Ads even from equally validSOURCE: IFIC Foundation, 2004 sources.
  65. 65. Most Popular Sources of Food and Nutrition Information• Television 62%• Magazines 48%• Newspapers 33%• Internet 23%• diet books 19%The information consumers encounter each day is filledwith messages that are often conflicting … and confusingDifficult for consumers to determine WHO and WHAT is credible
  66. 66. The difficult relationship doctors-journalists...”Never even whisper to a reporter anything you would not care to see in screaming headlines”... N Engl J Med, 1983
  67. 67. A Golden Opportunity for Health ProfessionalsNutrition Sources Rated “Very Valuable” by consumers Doctors 92% Registered dietitians 90% Nutritionists 90% Magazines 87% Nurses 85% Newspapers 82% TV news 79% Family and friends 69% Radio news 65% Other non-news TV 61% Internet 61%ADA Trends Survey 2000 0% 20% 40% 60% 80% 100%
  68. 68. Thank you for your attention