Dietetics and Nutrition in the Mediterranean

By Dr. ssa Fabiana Avallone

Obesity and BMI Obesity is a condition of excess body fat.Obesity is currently defined using body mass index (BMI). BMI is calculated as weight (kg)/ height squared (m²) and is indipendent of sex. BMI is significantly correlated with total body fat content and it’s now internationally accepted as a means of identifying overweight and obesity. The risks of developing type 2 diabetes, heart disease and cancer all increase as BMI increases, with the lower risk generally seen at BMIs of 22 to 25 kg/m². Mortality increases gradually above a BMI to 25 kg/m².

Obesity and BMI

BMI kg/m² OBESITY CLASS

Underweight <18.5

Normal 18.5 – 24.9

Overweight 25.0 – 29.9

Obesity 30.0 – 34.9 I

Obesity 35.0 – 39.9 II

Extreme obesity

≥ 40 III

Obesity: epidemiology Obesity is a condition of excess body fat.

For the first time in history, most US adults are overweight or obese, and as such they have substantially increased morbidity and mortality from hypertension, stroke, coronary artery disease, dyslipidemia, type 2 diabetes, sleep apnea and numerous other conditions.

Higher BMI also increases all-cause mortality.

Obesity: epidemiology According to NHANES 1999-2000 (National Health and Nutrition Examination Surveys), an estimated 64% of persons in the United States are overweight (BMI 25-30) or obese (BMI ≥30); that is 8% higher than 1988-1994 and 17% higher than in 1971-1974. Among adults 20 to 74 years old, the estimated prevalence of obesity (BMI ≥30) doubled between NHANES 1976-1980 AND NHANES 1999-2000 from abaut 15 to 31%. The consequences for the health care system are important for the obesity-related comorbidities.

Obesity as a disorder of energy balance Obesity can develop only as a result of an imbalance between energy intake and energy expenditure.High energy intake leads to obesity only if it is not matched by high energy expenditure, and low energy expenditure leads to obesity only if it is not matched by low energy intake. When intake is lower than expenditure, negative energy balance occurs, and body energy stores are reduced. When energy intake exceeds expenditure, positive energy balance occurs, and body energy stores are increased.

Obesity as a disorder of energy balance COMPONENTS OF ENERGY BALANCE (positive or negative)

Energy intake We take in energy in the foods we eat. The major macronutrient sources of dietary energy are fat, carbohydrates, protein and alchool.

Energy expenditure1. Resting Energy Expenditure2. Physical Activity Energy Expenditure3. Thermic Effect of Food

Obesity as a disorder of energy balance Energy expenditure Total energy expenditure (TEE) is the sum of resting energy expenditure, thermic effect of food and physical activity-related energy expenditure. Resting Energy Expenditure REE The majority of human energy expenditure is through the body’s metabolism at rest, comprises 60 to 80% of (TEE) in most people. REE is the energy required by the body to maintain basic physiologic functions such as pumping blood, making hormones and maintaining body temperature (in average muscle 25%, brain 20% and liver 22% of REE)

Obesity as a disorder of energy balance Energy expenditure Total energy expenditure (TEE) is the sum of resting energy expenditure, thermic effect of food and physical activity-related energy expenditure. Physical Activity Energy Expenditure PAEEIs the component of energy expenditure that is most under voluntary control because it is influenced most strongly by the amount of PA. PAEE is the most variable component of energy expenditure and can easily range from 10% of TEE in sedentary persons to 40% of TEE in active persons.

Obesity as a disorder of energy balance Energy expenditure Total energy expenditure (TEE) is the sum of resting energy expenditure, thermic effect of food and physical activity-related energy expenditure. Thermic Effect of Food TEFTEF is the increase in energy expenditure associated with digestion, absorption and storage of ingested macronutrients, usually 7 to 10% of the total caloric content of the meal. The energy cost of a meal is associated with the macronutrient composition of food consumed, with the TEF higher for protein, than for carbohydrates and fat.

NUTRIENT RECOMMENDED INTAKE

Calories Approximately 500-1000 Kcal/d reduction from usual intake. 1200 – 2000 Kcal/d

Carbohydrate 40-55% of total energy

Polysaccharides Emphasize whole grains, legumes, vegetables

Monosaccharides Emphasize fruits, no sugar

Glycemic index Emphasize foods with a low GI

Fiber total 20-30 g/d (15-25 g/1,000 Kcal)

Protein 15-30% of total energy

Total fat ≤ 30% of total energy

Saturated fatty acid 8-10% of total energy

Monounsaturated fatty acids

≤15% of total energy

Cholesterol ≤ 300 mg/d

Calcium 1000 – 1500 mg/d

Kcalories on 100 grams of vegatables 1. 9 Kcal Fennels( cellulose)2. 11 Kcal Zucchine3. 12 Kcal Chicory4. 13 Kcal Red radicchio5. 14 Kcal Cucumber6. 15 Kcal Escarole7. 16 Kcal Endive8. 17 Kcal Chard9. 18 Kcal Eggplant, Green beans, turnip10.19 Kcal Lettuce, Beetroot

Top 10 richest protein and lowest kilocalorie food/100g

1. 43 Kcal/11 g egg white2. 57 Kcal/11 g octopus3. 68 Kcal/13 g squid, /14 g ray4. 71 Kcal/14 g shrimp, /17 g cod5. 72 Kcal/14g cuttlefish, /11 g palourde6. 78 Kcal/16 g John dory, /16 g ombrine7. 80 Kcal/16 g dogfish, /19 g pike8. 83 Kcal/17 sole9. 84 Kcal/12 mussel10. 86 Kcal/15 trout

Mediterranean Diet Rules• vegetables (at least 300-400 g a day) • fruit (at least 4 pieces or 400 g a day)• legumes and pulses• grains, pasta and/or bread (mostly whole) • olive oil and nuts• water (more than 2 liters per day)• wine during meals ( maximum 2 glasses per day )• seafood (fish, shellfish, mollusc), 4-6 times a week• yoghurt, 2 - 4 times per week• cheese, 1 - 4 times per week• milk, 1 - 2 times per week• eggs, 1 - 4 eggs per week (maximun 1 per day)• poultry, 1 - 2 times per week• red meat, 0 - 1 time a week • sweets, 0 - 1 time per week

Diabetes mellitus: epidemyology Diabetes mellitus is occuring at epidemic rates in the US and in most parts of the world. The number of adults with diabetes in the world is projected to increase from 135 million in 1995 to 300 million in 2025. In the US approximately 15 million have diabetes and approximately 15 million have impaired fasting glucose levels. Of special concern is the emergence of type 2 diabetes in adolescents, closely linked to the fourfold increase in prevalence of obesity in children and teens in the past 30 years. Diabetes is the fifth leading cause of death in the US and cost annually 132 billion dollars.

Diabetes mellitus: classification Metabolic derangements in the metabolism of glucose and profound abnormalities in the metabolism of fat, protein, and other substances characterize the pathology of diabetes. A heterogeneous disorder both genetically and clinically, all classifications of diabetes have in common hyperglycemia, attributable to either insulin insufficiency or insulin resistance.

1. Insulin-dependent diabetes mellitus (type 1)2. Non-insulin-dependent diabetes mellitus (type 2)

Etiologic classification of diabetesDiabetes1. Type 1 diabetes (beta-cell destruction with lack of

insulin)2. Type 2 diabetes (insulin resistance with relative

insulin deficiency)3. Other specific types: genetic defects of beta-cell

function; genetic defects of insulin action; diseases of the exocrine pancreas; endocrinopathies (acromegaly); drug or chemical-induced; infectious;

4. Gestational diabetes mellitus

Diabetes mellitus: classification Type 1 diabetes accounts for approximately 5% of

diabetes and is manifested by insulin deficiency caused by destruction of the pancreatic beta-cells.

Type 2 diabetes accounts for about 90% of diabetes and is caracterized by two primary defects: insulin resistence (diminished tissue sensitivity to insulin) and impaired beta cell function (delayed or inadequate insulin release.

Other causes account for the remaining 5% of diabetes in the United States

Criteria for diagnosis of diabetes

1. Symptoms of diabetes plus casual plasma glucose values of ≥ 200 mg/dL. Casual is defined as any time of day without regard to time since last meal. Classic symptoms of diabetes include polydipsia, polyuria and unexplained weight loss.

2. Fasting plasma glucose value ≥ 126 mg/dL. Fasting is defined as no energy intake for at least 8 hours.

3. 2-hour postload plasma glucose value of ≥ 200 mg/dL during an oral glucose tolerance test.

Diabetes mellitus: role of hormones Glucose homeostasis is orchestrated by an exquisite

interplay of pancreatic and gut hormones. The most important are insulin and glucagon.

Insulin is the hormone primarily responsible for the metabolism and storage of the body fuels that are ingested. The pancreas sustains a basal level of insulin release and secrets additional insulin in response to increased blood glucose after a meal. The postprandial secretion of insulin promotes glucose, amino acids, and fat uptake bi tissues (primarily liver, adipose and muscle tissue) where the glucose is used or stored.

Diabetes mellitus: role of hormones Insulin production decreases as the blood glucose

level decreases.

Glucagon, is secreted by the pancreatic α cells in response to decreased blood glucose levels and under conditions of stress. Glucagon stimulates glucose release from liver.

The balance between insulin and glucagon levels is vital for normal glucose homeostasis, fatty acid metabolism, and protein preservation.

CATEGORY RECOMMENDATION

Weight management Attain and maintain desirable body weight (BMI ≤ 25)

Carbohydrate 40-55% of total energy

Polysaccharides Emphasize whole grains, legumes, vegetables

Monosaccharides Emphasize fruits, no sugar

Glycemic index Emphasize foods with a low GI

Fiber total 25-50 g/d (15-25 g/1,000 Kcal)

Protein 15-30% of total energy

Total fat ≤ 30% of total energy

Saturated fatty acid ≤ 10% of total energy

Monounsaturated fatty acids

12-15% of total energy

Polyunsaturated fatty acids

≤ 10% of total energy

Cholesterol ≤ 200 mg/d

Mediterranean Diet Rules• vegetables (at least 300-400 g a day) • fruit (at least 4 pieces or 400 g a day)• legumes and pulses• grains, pasta and/or bread (mostly whole) • olive oil and nuts• water (more than 2 liters per day)• wine during meals ( maximum 2 glasses per day )• seafood (fish, shellfish, mollusc), 4-6 times a week• yoghurt, 2 - 4 times per week• cheese, 1 - 4 times per week• milk, 1 - 2 times per week• eggs, 1 - 4 eggs per week (maximun 1 per day)• poultry, 1 - 2 times per week• red meat, 0 - 1 time a week • sweets, 0 - 1 time per week

The Glycemic Index Ranking Classification GI range Examples

Low GI 55 or less

most fruits and vegetables (except potatoes and

watermelon), grainy breads, pasta, legumes/pulses, milk,

yoghurt, products extremely low in carbohydrates (some cheeses,

nuts), fructose

Medium GI 56–69 Whole wheat products, basmati rice, sweet potatoes

High GI 70 and above

corn flakes, rice crispies, baked potatoes, watermelon, croissants, white bread, extruded breakfast cereals, most white rices straight

glucose (100)