Lesson 4 : Nutrition Disorders Obesity and health consequences.

Lesson 4 : Nutrition Disorders

Obesity and health consequences

Physical Activity, Calories and Obesity:Physical Activity, Calories and Obesity:The Challenge of Advances in TechnologyThe Challenge of Advances in Technology

The epidemic of obesity, diabetes and the metabolic syndrome

Technology and reduced physical activity

Technology and the availability of calories

The need for integrated solutions

Obesity: definition

• Chronic disease characterized by accumulation of fat. Obesity is defined as a condition when ideal body weight is exceeded by 20%

• Medical condition responsible for serious co-morbidity and mortality.

Psychosocial consequence

• Economical impact of obesity

• Prejudice and Discrimination

• Considered lazy, incompetent and more often absent due to illness

• Confronted with more problems at job application : – Very few executive managers with overweight in the US

Epidemiology

00

1010

2020

3030

4040

5050

1960196019701970

1980198019901990

2000200020102010

2020202020302030

USAUSA

EnglandEngland

MauritiusMauritius

AustraliaAustralia

BrazilBrazil

Population Population percentage percentage with BMI with BMI >>

30kg/m30kg/m22

Obesity rates:

current and projected

Collated by the IOTF from recent surveysCollated by the IOTF from recent surveys

YugoslaviaYugoslaviaGreeceGreece

RomaniaRomaniaCzech Rep.Czech Rep.

EnglandEnglandFinlandFinland

GermanyGermanyScotlandScotlandSlovakiaSlovakiaPortugalPortugal

SpainSpainDenmarkDenmarkBelgiumBelgiumSwedenSwedenFranceFrance

ItalyItalyNetherlandsNetherlands

NorwayNorwayHungaryHungary

SwitzerlandSwitzerland% BMI % BMI >>3030

3030 40403030004040 2020 1010 1010 2020

Male and Female Obesity Levels in

Selected European CountriesWomenWomen MenMen

<10% 10-15% <10% 10-15% >15%>15%

Prevalence of Obesity Prevalence of Obesity among U.S. Adults, among U.S. Adults, BRFSS, 1990BRFSS, 1990

(BMI > 30)Height Weight152 (60) 69 (153)167 (66) 84 (186)178 (70) 94 (207)

BMI = 30

<10%<10% 10-15% 10-15% >15% >15%


<10% 10-15%<10% 10-15% >15% >15%


<10%<10% 10-15% 10-15% >15%>15%


Prevalence in 2000 = 30.5%

1980s = X generation

1990s = Y generation

2000s = XXL generation

The Developing Generations

Source: Mokdad et al., Diabetes Care 2000;23:1278-83.

Diabetes Trends Among Adults in the U.S., BRFSS 1990

<4% 4% -6% >6%


Diabetes Trends Among Adults in the U.S., BRFSS 1991-92


Source: Mokdad et al., J Am Med Assoc 2001;286(10).


What causes Obesity?

• Genetic predisposition

• Disruption in energy balance

• Environmental and social factors

The physiology of weight gain

Energy input Energy output

Control factors

Genetic make-upDiet

ExerciseBasal metabolism

Thermogenesis

Aetiology of obesityLIFESTYLE

PSYCHOLOGICAL MEDICAL

GENETIC

OBESITY

IA6

Thrifty genotype - feast and famine theory

Those who are most efficient in storing energy as fat during time of famine are

the survivors. Therefore that genetic predisposition is favoured in a

population. When that population experiences times of constant ‘feast’ i.e. a western diet, they become obese and

develop diabetes.

GLUCOSE SENSING IN MATURITY GLUCOSE SENSING IN MATURITY ONSET DIABETES OF THE YOUNGONSET DIABETES OF THE YOUNG

NORMALNORMALBASALBASALSTATESTATE

HYPERGLYCEMIAHYPERGLYCEMIASENSED ASSENSED AS

EUGLYCEMIAEUGLYCEMIAIN MODYIN MODY

NORMAL NORMAL STIMULATIONSTIMULATION

OF INSULINOF INSULINSECRETION BYSECRETION BY

HYPERGLYCEMIAHYPERGLYCEMIA

GLUCOSEGLUCOSEGLUCOSEGLUCOSE

HKHK

G6PG6P

METABOLITESMETABOLITES

hkhk

G6PG6P


HKHK

G6PG6P


GLUCOSEGLUCOSE

Environmental effects on the risk for type 2 diabetes mellitus

• Pima Indians living “on the rez” in Arizona have among the highest prevalences of diabetes and obesity of any group in the country.

• However, most of the Pima in Mexico are lean and nondiabetic.

• The difference? The Mexican Pima still live a subsistence lifestyle, farming beans and corn in the arid mountains.

Prevalence of Type 2 Diabetes by Weight

0

5

10

15

20

25

30

35

Perc

en

t w

ith

Typ

e 2

Dia

bete

s

<22

22-2

5

25-3

0

30-3

5

>35

Body Mass IndexAge 20-54 Years

Undiagnosed

Diagnosed

0

5

10

15

20

25

30

35

<22

22-2

5

25-3

0

30-3

5

>35

Body Mass IndexAge 55-74 Years

The “Thrifty” HypothesisThe “Thrifty” Hypothesis

FAVORINGFAVORINGENERGYENERGY

UTILIZATIONUTILIZATION

The GrasshopperThe Grasshopper

FAVORINGFAVORINGENERGYENERGY

STORAGESTORAGE

The AntThe Ant

FEASTFEAST FAMINEFAMINE FEASTFEAST FAMINEFAMINE

REPRO-REPRO-DUCTIVEDUCTIVE

ADVANTAGEADVANTAGEDEATHDEATH OBESITY/OBESITY/

DIABETESDIABETESSURVIVALSURVIVAL

Normal glucose toleranceNormal glucose tolerance

8080

120120

160160

200200

240240

280280

320320

360360

400400

Pla

sm

a g

lucose (

mg

/dl)

Pla

sm

a g

lucose (

mg

/dl)

00 6060 120120 180180

Time (min)Time (min)

NormalNormal

00

5050

100100

150150

Pla

sm

a in

su

lin

(u

U/m

l)P

lasm

a in

su

lin

(u

U/m

l)00 6060 120120 180180


Impaired glucose tolerance:Impaired glucose tolerance:Hyperinsulinemia and insulin resistanceHyperinsulinemia and insulin resistance

8080

120120

160160

200200

240240

280280

320320

360360

400400

Pla

sm

a g

lucose (

mg

/dl)

Pla

sm

a g

lucose (

mg

/dl)

00 6060 120120 180180


Impaired glucose Impaired glucose tolerancetolerance

NormalNormal

00

5050

100100

150150

Pla

sm

a in

su

lin

(u

U/m

l)P

lasm

a in

su

lin

(u

U/m

l)00 6060 120120 180180


Insulin Resistance in Type 2 DM

0

100

200

300

400

Glu

cose D

isp

osal R

ate

(m

g/M

2/m

in)

10 100 1000 10000

Insulin Concentration (uU/ml)

Diabetes

Control

INSULIN-STIMULATED GLUCOSE INSULIN-STIMULATED GLUCOSE UPTAKE IN MUSCLE AND FATUPTAKE IN MUSCLE AND FAT

4

41

4 1

INS

44

4

G

GG

G

44

4

4 4

14 1

44

4

4 4

14 1

INS

TYR KINASEIRS-1PI3K

G

GLYCOGENGLYCOLYSIS

UNDERSTANDING TYPE 2 UNDERSTANDING TYPE 2 DIABETESDIABETES

LIPIDSLIPIDS CARBOHYDRATECARBOHYDRATE

WHICH IS THE CART AND WHICH IS THE HORSE?

HYPERINSULINEMIA

INSULIN RESISTANCE

Is Insulin Resistance a Cause or Effect of Diabetes?

• “Beta cell hyperresponsiveness is the earliest event in the development of type 2 diabetes” in rhesus monkeys, preceding the onset of insulin resistance.– Hansen and Bodkin, Am J Physiol 259:R612

(1990)

What does the “thrifty phenotype” look like in a calorie restricted,

natural setting?• Aboriginal Australians exposed to Western

diet/lifestyle develop type 2 diabetes and obesity in alarming proportions, similar to native Americans.

• O’Dea has studied aboriginal Australians living in the bush and has found:– Lean individuals: average BMI 16 kg/m2– They are relatively hypoglycemic (68 mg/dl) while having

relative hyperinsulinemia (13 uU/ml)

Fasting hyperinsulinemia predictstype 2 diabetes independent of

insulin resistance• Among 262 healthy Pima Indians, 48 (18%)

developed diabetes during a 4-6 year follow-up period.

• Fasting insulin and insulin responsiveness predicted the development of diabetes and the concomitant decline in insulin secretion.– Pratley, Weyer, Hanson, Tataranni, Shuldiner, and Bogardus (2000)

Is Insulin Resistance a Cause or Effect of Diabetes?

• Isolated insulin resistance is well tolerated in transgenic animals and does not, by itself, lead to diabetes.

• Beta cell abnormalities, on the other hand, do predispose to overt diabetes in animal models.

• Isolated hyperinsulinemia can cause insulin resistance just as well as insulin resistance can cause hyperinsulinemia.

Caloric Excess

CNS: leptin resistance

PERIPHERAL:hyperinsulinemiainsulin resistancehyperlipidemiahyperglycemia

leptin

Technological advances have taken away much of the activity in our

lives• Fewer active jobs• Greater reliance on motorised transport• Energy-saving devices in the home, at work and

shopping environment• Attractive and cheap home screen entertainment

CHALLENGE IS TO COUNTERACT THESE EFFECTS

Cellular phones and remote Cellular phones and remote controls deprive us from walking!controls deprive us from walking!

20 times daily x 20 m = 400 20 times daily x 20 m = 400 mm

Walking distance Walking distance lost/yearlost/year400x365 = 146,000 m400x365 = 146,000 m

146 km = 25 h of 146 km = 25 h of walkingwalking

1 h of walking = 113-226 1 h of walking = 113-226 kcalkcal

Energy saved =2800-6000 kcalEnergy saved =2800-6000 kcal

Rössner, 2002Rössner, 2002

High-Tech increases Body Weight

0.4-0.8 kg adipose tissue0.4-0.8 kg adipose tissue

Biological and cultural mismatches to the modern

environment FOOD

• Strong signals to eat

• Weak signals to stop

• Increased availability

• Eating is rewarding

• No viable alternatives

• Eating well is high status

ACTIVITY• Weak activity signal • Strong signals to stop• Reduced availability• Inactivity is rewarding• Inactivity is a viable

alternative• Inactivity is high status

The Evolution of Man

Since 1850

Daily Energy Expenditure in Primitive Hunter -Gatherer -Farmers versus Sedentary Adults in USA

Machiguenga Indians in Peru

Kilocalories per Kilogram per Day

Primitive Modern0

10

20

30

40

50

60MenWomen

∆ = 42% ∆ = 27%

Montgomery E., Fed Proceed 37:61-64, 1978

Denis Diderot - Pictorial Encyclopedia of Trades and Industry ( France 1740-1780)

“From the time of the Roman Conquest to the time of the Civil War in the United States (1860s), there was no improvement in the efficiency in the movement of military troops or supplies. This was changed by the use of the steam engine to power ships and the locomotive.”

The Men Who Dared:Building the Transcontinental RailroadStephen Ambrose 2000

““Required daily activity” between 1850 and 1950 forRequired daily activity” between 1850 and 1950 formany people in technologically advancing societies many people in technologically advancing societies decreased substantially and this decrease was easily decreased substantially and this decrease was easily observable.observable.

Since the 1950s there has continued to be a decline in Since the 1950s there has continued to be a decline in “required daily activity” in many societies, but this “required daily activity” in many societies, but this decrease in more subtle and less well documented. decrease in more subtle and less well documented.

Decline in Daily Required Activity Resulting from Decline in Daily Required Activity Resulting from the Industrial Revolutionthe Industrial Revolution

“ These lumberjacks worked10-12 hours , six days per weekfrom April through Novemberlogging the giant redwoodtrees. Their primary equipmentincluded 9-pound axes, two-mansaws, buck saws, hand winches and wedges.”

History of the Sierra NevadaC. Taylor, 1996

Required Daily Activity High for Many Workers 1n 1900

RMR = 1Kcal/Kg/Hr (VO2 = 3.5 ml/kg/min)

50 kg body weight = 50 x 24 = 1200 Kcal/day



PAL = 1.0

WHO Obesity Guidelines, 2000 Technical Report Series 894

Physical Activity Level - PAL Multiple of Resting Metabolic Rate

MEN WOMENRMR 1.00 1.00Very Light <1.46 <1.41Light 1.46 - 1.65 1.41 - 1.55Moderate 1.66 - 1.90 1.56 - 1.75Heavy 1.91 - 2.25 1.76 - 2.05Exceptional >2.25 >2.05

WHO Obesity Guidelines, 2000 - Technical Report Series 894

0

0.5

1

1.5

2

2.5

3 PAL

Variations in Energy Expenditure DueDue to Daily Physical Activity

PAL 1.0 1.30 1.58 1.75 2.00 2.65 2.80Kcal/day* 1680 2184 2644 2940 3360 4550 4800

RMR

Sedentary Moderately Active

VeryActive

Primitive Man

Finnish Lumberjacks

Light Activity

* Kcal/day for 70 kg person

WHO GOAL

Declines in on-the-job energy expenditure

during the past 50 years

Labor savings devices that decrease required energy expenditure

• Computers • Satellites• Electric typewriters • Television• Electric calculators • Video cameras and recorders• Photocopy machines • Robotics• Telefax machines • Automated on-job equipment• Telephones • Gas/electric home equipment

• digital • Microwave ovens • portable •• answering machines •• voice-mail

People movers - escalatorsWireless technology

Frequent Decreases in Short Bouts of Low

Intensity Activity Can Significantly

Alter Energy Balance Over 5 years

Only 165 Kcal/week equal in energy to 10.1 pounds or 4.6 kilograms of body fat in 5 years

If 50 kilogram person exchanged walking around office for sitting at computer for 5 minutes per hour, 8 hours per day, 5 days per week, 50 weeks per year for 5 years = amount of energy in 10.1 pounds or 4.6 kilogram body fat.

Wireless Technology Likely to Decrease Required Daily Activity

Technology and Inactivity - Future

Projections for further decline in energy expenditure in the population due to continued decrease in daily required physical activity over next two decades

� Reduce commuting to work

� Computer to bank, shop, etc.

� More job tasks automated � New technologies

Alan Greenspan - Chairman, Board of Governors of the Federal Reserve System

The major cause for the continued increase in the US economy without an increase in inflation throughout the 1990s was an increase in individual worker productivity.

It’ll cut down on the work breaks!

Individual worker productivity increased by:

• Working more hours - in 1998 US worker averaged 1950 hours/year while European workers average 1558 hours/year on-the-job: 25% more hours per year.

• Increase in worker efficiency by reducing amount of physical movement time. Moving around is a major cause of inefficiency for computer & communications-based industry.

A Problem and challenge!

The US model used to increase economic productivity is considered an approach to be emulated by leaders in many developing countries

MOSPA Study Population Adults 25 - 65 Years

• Beijing China (627 men, 575 women)

• Friuli Italy (700 men, 391 women)

• Warsaw Poland (535 men, 469 women)

• WHO-MONICA project monitors global trends and determinants of CVD• MOSPA (MONICA Optional Study of Physical Activity) questionnaire was developed to assess physical activity behaviors of participating MONICA sites• MOSPA data collected 1987-1994

Percent Time Spent by Adults in Different Categories of Physical Activity in China, Italy, and Poland

Percent Time Spent by Adults in Different Categories of Physical Activity in China, Italy, and PolandPhysical Activity in China, Italy, and Poland

% time

Data from WHO MONICA report, 2000

Occupational Household Recreational Transportation

0

10

20

30

40

50

60

70

80

90

Occupational Household RecreationalTransportation

0

10

20

30

40

50

60

70

80

90

China ItalyPoland

MEN WOMEN

Increased Time at Computer/TV/Video

Decreases Time for Leisure-TimePhysical Activity

>

TV Video Tapes Video games

Computer Movies TOTAL0

1

2

3

4

5

6

2-7 years8-18 years

Time Spent by USA Children Viewing Electronic Media

Hours/day

Kids and Media. A Kaiser Family Foundation Report, November 1999, Menlo Park, CA

National sample of 3,158 children in the USA

"The Media Generation"

2.8

5.2

Why don’t you get off the computer and watch TV?

New Remote Control

Can Be Operated by

Remote No more leaning forward to

get remote from coffee table

means greater convenience

for TV viewers.

Television watching became

even more convenient

with Sony’s introduction

of a new remote-controlled

remote control.

Potential reduction of leisure-time physical activity as computer/communication

technology advances penetrate the masses

Technology and Leisure Activity

• Increased participation in computer games• Increased use of computer as a communication

device for recreational purposes (chat rooms, etc.)• Increased use of home-based video - including

video access on the internet• Continued watching of television - cable, satellite

Physical Activity and Obesity

• Risk of overweight low if PAL is ≥ 1.75 A PAL of >1.75 is needed to prevent “unhealthy weight gain” [based on results of 40 international studies]

• Prevalence of PAL ≤1.75 rapidly increasing in developed and developing countries - especially as they adopt computer and communication technology.

WHO Obesity Guidelines, 2000 - Technical Report Series 894

0

0.5

1

1.5

2

2.5

3 PAL


PAL 1.0 1.30 1.58 1.75 2.00 2.65 2.80Kcal/day* 1680 2184 2644 2940 3360 4550 4800

BMR


VeryActive

Primitive Man

Finnish Lumberjacks

Light Activity


WHO GOAL

0

0.5

1

1.5

2

2.5

3 PAL


PAL 1.0 1.30 1.52 1.75 2.00 2.65 2.80Kcal/day* 1680 2184 2553 2940 3360 4550 4800

BMR


VeryActive

Primitive Man

Finnish Lumberjacks

Light Activity


GOAL

30 Min. Mod Intensity - USA (1995)

60 Min. Mod Intensity - Canada (2000) & IOM (2002)

0

0.5

1

1.5

2

2.5

3 PAL


PAL 1.0 1.30 1.52 1.75 2.00 2.65 2.80Kcal/day* 1680 2184 2553 2940 3360 4550 4800

BMR


VeryActive

Primitive Man

Finnish Lumberjacks

Light Activity


GOAL

30 Min. Mod Intensity - USA (1995)

+756 Kcal /day (WHO 2000)

60 Min. Mod Intensity - Canada (2000)

ACTIVITY INTERVAL!!

Body Mass

Energy Intake

Energy Expenditure

Large portion sizeHigh caloriedensityLow cost

OccupationalTransportationHousehold

Sedentary

Recreational ?

Factors Contributing to Recent Increases in Body Mass in the USA & Other Developed Countries

Low cost of increasing portion size (supersizing or value marketing) is a major profit item for restaurants & fast food markets

7-Eleven Gulp to Double Gulp Coke Classis 37 cents buys 450 more calories (150 to 600 calories)

Movie popcorn (unbuttered) - from small to large increases cost by $1.31 but increases calories from 400 to 1160

Cinnabon - Ordering a Cinnabon costs 48 cents more than a Minibon but increases calories from 300 to 670

Advances in Technology Throughout the Food Supply Chain Advances in Technology Throughout the Food Supply Chain Has Reduced the Cost of High Calorie Low Nutrient FoodHas Reduced the Cost of High Calorie Low Nutrient Food

High calorie foods and drinks replacing low calorie items

Starbucks Venti Coconut Crème Frappuccino “coffee” = 870 calories

Adding “Value Meals” for single item orders

Burger King Whopper ($2.24 & 680 calories) to Whopper Values Meal - King ($4.80 & 1,710 calories

Advances in Technology Throughout the Food Supply Chain Advances in Technology Throughout the Food Supply Chain Has Reduced the Cost of High Calorie Low Nutrient FoodHas Reduced the Cost of High Calorie Low Nutrient Food

Double Cheese Burger = 690Super Size Coke = 280Biggie Fries = 570 TOTAL = 1,540

CALORIES

62 grams of fat

High Caloric Density FoodAlways Available at Low Cost

Ad in Sports Illustrated 15/06/02

0

10

20

30

40

50

60

70

1970-74 1975-79 1980-84 1985-89 1990-94 1995-99

Introduction of New Larger Portions in the USAIntroduction of New Larger Portions in the USA

Young & Nestle. AJPH,92:246, 2002

Dinner plate diameter 25% larger in 2000 vs. 1990

McDonalds’ Worldwide Influence

28,000 restaurants worldwide - 2,000 new/year Hire more than one million people per year Largest private owner of real estate property in world More $$ spent on advertising than any other US corp. 90% of children can identify Ronald McDonald - only

Santa Claus has higher recognition factor The McDonald’s arches more widely recognized than

the Christian cross FAST FOOD NATION - Eric Schlosser 2001

Obesity and sedentary living in European adults

Martinez-Gonzalez et al. 1999, IJO, 23, 1192-1201

0

2

4

6

8

10

12

14

<15 15-20 21-25 26-35 >35

Men Women

%Obese

Hrs sat/wk

Hourly movement counts of obese and non-obese adults: Weekdays

0

100

200

300

400

500

600

700

07:00 08:00 09:00 10:00 11:00 12:00 13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00 21:00 22:00 23:00 )

CS

A c

ou

nts

.min

-1

0.0

50.0

100.0

150.0

200.0

250.0

300.0

350.0

400.0

% p

arti

cip

ants

BMI<30BMI>30% BMI<30% BMI>30

100

50

Cooper et al., EJCN, 2000

Hourly movement counts of obese and non-obese subjects: Weekends

0

100

200

300

400

500

600

700

7:00 8:00 9:00 10:00 11:00 12:00 13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00 21:00 22:00 23:00

Time of day (hour from)

CS

A c

ou

nts

.min

-1

0.0

50.0

100.0

150.0

200.0

250.0

300.0

350.0

400.0

% p

arti

cip

an

ts

BMI<30BMI>30% BMI<30% BMI>30

100

50

Eat to

Live!Live to

Eat!

““EAT TO LIVE”EAT TO LIVE”Intake = ExpenditureIntake = Expenditure

Weight StableWeight Stable

““LIVE TO EAT”LIVE TO EAT”Intake > ExpenditureIntake > Expenditure

ObeseObese

Ageing and Energy Expenditure

James, Ralph and Ferro-Luzzi, 1989James, Ralph and Ferro-Luzzi, 1989

Kca

ls/d

Kca

ls/d

IntenseIntenseexerciseexercise OccupationalOccupationalDiscretionaryDiscretionary

Sitting, coffee,Sitting, coffee,smokingsmoking

Basal metabolicBasal metabolicraterate

Dietary induced Dietary induced thermogenesis thermogenesis

70 kg, Aged 25 years70 kg, Aged 25 years 70 kg, Aged 70 years70 kg, Aged 70 years

40004000

20002000

00

30003000

10001000

Fat as the Macronutrient Culprit

Adapted from WHO Consultation 1998Adapted from WHO Consultation 1998

ProteinProtein CarbohydratCarbohydratee FatFat

Energy content per gEnergy content per g

Ability to end eatingAbility to end eating

Ability to suppress Ability to suppress hungerhunger

Storage capacityStorage capacityPathway to transfer Pathway to transfer

excessexcess to alternative to alternative compartmentcompartmentAbility to stimulate own Ability to stimulate own

oxidationoxidation

44

HighHigh

HighHigh

LowLow

YesYes

ExcellentExcellent

44

ModerateModerate

HighHigh

LowLow

YesYes

ExcellentExcellent

99

LowLow

LowLow

HighHigh

NoNo

PoorPoor

Dietary fatTypical Belgian dietTypical Belgian diet

Carbohydrate40–50%

Protein15–20 %

Fat40%

Desired Belgian dietDesired Belgian diet

Carbohydrate45–55%

Protein15–20 %

Fat30%

Staessen L. et al. : Ann. Nutr. Metab. 1998; 42; 151-159

Contribution of fat, protein, carbohydrate and alcohol to the energy intake in the

average British diet

Energy needsMeasurement of Energy Intake

Consequences of obesity

Cardiovascular risk factorsRespiratory disease

Heart disease

Gallbladder disease

Hormonal abnormalities

Hyperuricaemiaand gout

Stroke

Diabetes

OsteoarthritisCancer

……because of fat infiltrationbecause of fat infiltrationin eyelids...in eyelids...

Blindness in a child...

Obesity : Definition

• APPLE TYPE :Central or abdominal adiposity (ANDROID) increased WHR & associated with higher morbidity risk. ♂ > ♀

Android obesity

or


• PEAR TYPE : GYNOID or typical female distribution of fat : less health risks

Gynoid obesity

or

visceral fat measurement using standard procedure at L5

Waist to hip circumferences

Correlates with visceral fat (Ashwell et al, 1985

Coefficient of Variation in measurement about 2%

WHO recommendations on methdology

Epidemiological correlates with obesity morbidity


• WHR > 0.95 (♂) & > 0.80 (♀) : increased health risk

Visceral Obesity and the Insulin Resistance Syndrome

Excess visceralabdominal adipose

tissue

Insulin resistance andhyperinsulinaemia

Atherogenic dyslipidaemiaTotal-C LDL-C HDL-C Triglycerides Small, dense LDL Apolipoprotein-B

HypertensionLVH

Congestive heart failure

Prothrombotic statePAI-1 Factor VII Fibrinogen

Glucose intolerance

Metabolic Syndrome Defined by ATP III (2001) as ≥ 3 of any of the following

Waist circumference ≥ 102 cm in men and 88 cm in women

Triglyceride concentration ≥ 150 mg/dL (1.69 mmol/L

HDL-C ≤ 40 mg/dL (1.04 mmol/L) in men and ≤ 50 mg/dL (1.29 mmol/L) in women

Blood pressure ≥ 130/85 mm Hg

Blood glucose ≥ 110 mg/dL (6.1 mmol/L)

0

5

10

15

20

25

30

35

40

45

20-29 30-39 40-49 50-59 60-69 70+

Prevalence of Metabolic Syndrome in Men and WOMEN - USA

MEN (24.0%)WOMEN (23.4%)

Total = 47 million people

NHANES - 1994

AGE -YEARS

Mexican American = 31.9%

Obesity treatmentWhy?

• Obesity is a chronic condition

• Associated with co-morbidities–Type 2 diabetes–Arthritis

• Associated with risk factors–Hypertension–Dislipidaemia–Coronary heart disease

• Imposes a substantial economic burden

Abdominal Adiposity Increases CHD Risk Independently of BMI

0

20

40

60

80

100

120

140

Low (73.6)Medium (73.7-81.7)

High (81.8)

WaistCircumference

tertiles (cm)

High(25.2)

Medium(22.2-25.1)

Low(22.1)

BMI tertiles (kg/m2)

Ag

e-a

dju

ste

d C

HD

in

cid

en

ce

/10

0 0

00

pe

rso

n-y

ea

rs

Rexrode KM et al. JAMA, 1998; 280: 1843-8

7777

46465555

1061068989 9797

128128

110110

8383

Health consequences of obesity

Cardiovascular disease

Type 2 diabetes

Hypertension

Dyslipidaemia

Ischaemic stroke

Sleep apnoea

Degenerative joint disease

Some types of cancer

Gallstones

Gynaecologic irregularities

Clinical guidelines. National Heart, Lung, and Blood Institute Web site. Available at:http://www.nhlbi.nih.gov/nhlbi/cardio/obes/prof/guidelns/ob_gdlns.htm. Accessed July 31, 1998.

Greatly Increased Moderately increasedSlightly increased(relative risk >>3) (relative risk c. 2-3)(relative risk c. 1-2)

Diabetes Coronary heart disease Cancer (breast cancer in postmenopausal women, endometrial cancer,

colon cancer)Gall bladder disease Hypertension Reproductive hormone abnormalitiesDyslipidaemia Osteoarthritis (knees) Polycystic ovary syndromeInsulin resistance Hyperuricaemia and gout Impaired fertilityBreathlessness Fetal defects arising from maternal obesitySleep apnoea Low back pain

Increased anaesthetic risk

IOTF Report

Relative risk of health problems associated with obesity

Proportion of disease prevalence attributable to obesity

Type 2 diabetes

Hypertension

Coronary heart disease

Gallbladder disease

Osteoarthritis

Breast cancer

Uterine cancer

Colon cancerWolf et al. Obes Res. 1998;6:97-106.

57%17%

17%

30%

14%

11%

11%

11%

Obesity related cardiovascular and renal risk

• Obesity is a independent risk factor for the development of CV and Renal disease, even in the absence of other pathologies

Burden of Disease

• Burden of disease analysis gives a unique perspective on health. Fatal and non-fatal outcomes are integrated, but can be examined separately as well.

• YLL - Years of Life Lost due to premature mortality

• +YDL - Years of Life Lost due to Disability

• DALY Disability Adjusted Life Years• one DALY is one lost year of ‘healthy’ life

Risk Factor• A condition, physical characteristic, or

behavior that increases the probability (the risk) that a currently healthy individual will develop a particular disease.

• Types of risks factors:– Environmental– Behavioral– Social– Genetic

Lifestyle Diseases and Risk Factors

• Diabetes

• Hypertension

• Heart Disease

• Cancer

• Genetic

• Obesity

• Eating Patterns

• Physical Activity

• Smoking

• Urbanisation

Coronary Heart Disease• Major risk factors

– High Total Cholesterol or LDL, Low HDL

– Elevated Homocysteine (low folate intake)

– Hypertension

– Cigarette Smoking

– Obesity

– Diabetes Mellitus

– Sedentary Lifestyle

– Excessive Alcohol

Factors which Influence Blood Lipid Levels

• Detrimental effect– Saturated fat– Trans fatty acids– Dietary cholesterol– Diabetes– Obesity

• central abdominal• Obesity• Sedentary Lifestyle

• Beneficial effect– Vegetables and fruits

– Polyunsaturated fatty acids

– Monounsaturated fatty acids

– Omega 3 fatty acids

– Dietary fibre

– Moderate alcohol

– Physical activity

Risk Factors for Hypertension

Detrimental effect• Age• Gender• Smoking• Obesity• Sodium• Alcohol• Stress

Beneficial effect

• Potassium

• Omega -3 fatty acids

• Physical activity

Health Agencies’ Recommendations for Prevention

of Hypertension

• Smoking cessation

• Reduce weight

• Reduce salt

• Moderate alcohol

• Reduce fat

• Increase fruit and vegetables

• Regular fish consumption

• Increase physical activity

Risk Factors for Diabetes

• Genetic

• Age

• Gender

• Obesity

• Eating pattern


• Hypertension

• Gestational Diabetes

• Urbanisation

Trend in Prevalence of Obesity*:NHANES Data

Kuczmarski RJ, et al. JAMA. 1994;272:205-211.

*BMI 27.3 mg/m2 for women; 27.8 kg/m2 for men

20

22

24

26

28

30

32

34

36

NHES (1960-1962)

NHANES I(1971-1974)

NHANES II(1976-1980)

NHANES IIIb(1988-1994)

US

Pop

ulat

ion

(%)

Type 2 Diabetes in the Pediatric Population: First Nation Data

Dean HJ. Diabetes. 1999;48(suppl 1):A168. Abstract 0730.Adapted with permission from the American Diabetes Association.

0

5

10

15

20

'86 '87 '88 '89 '90 '91 '92 '93 '94 '95 '96 '97 '98Year

New

Dia

bete

s P

atie

nts

Ref

erre

d to

Clin

ic

Prevalence of impaired glucose tolerance among children and adolescents with marked

obesity

– Aim• Determine the prevalence of IGT in a multiethnical cohort of 167

children and adolescents• OGTT with glucose, insulin, C-peptide

Sinha R, Fish G et al. NEJM 2002; 346: 802-10


obesity

Results• 25 % IGT in children (4-10y)• 21 % IGT in adolescents (11-18y)• Increased insulin values in IGT• 4 % insidous DM2 in adolescents



obesity

– Conclusion• High prevalence of IGT in children and adolescents with obesity

– > 95 percentile age and sex.

• Ethnicity not important• IGT accompanied by insulin resistance with adequate -cell

function• DM2 accompanied by insulin deficiency indicative of -cell

failure


Link Between Obesity and Type 2 Diabetes:Nurses’ Health Study

Colditz GA, et al. Ann Intern Med. 1995;122:481-486.

0

20

40

60

80

100

120

<22 22-22.9

23-23.8

24-24.9

25-26.9

27-28.9

29-30.9

31-32.9

33-34.9

>35

BMI (kg/m2)

Age

-Adj

uste

d Rel

ativ

e Ris

k

0

10

20

30

40

50

60

70

80

90

100

<22 <23 23-23,9

24-24,9

25-26,9

27-28,9

29-30,9

31-32,9

33-34,9

>=35

MalesFemales

Adapted from Chan JM et al. Diabetes Care 1994; 17: 961-9

Adapted from Chan JM et al. Diabetes Care 1994; 17: 961-9 Colditz et al. Ann Intern Med 1995; 122: 481-6

a

Age-adjustedrelative risk of type 2 diabetes

Obesity is a risik factor for type 2 diabetes

Link Between Obesity and Type 2 Diabetes:Nurses’ Health Study

Colditz GA, et al. Ann Intern Med. 1995;122:481-486.

0

10

20

30

40

50

60

70

80

<22.0 22.0-24.9 25.0-28.9 29+

BMI (kg/m2) at Age 18 Years

Ag

e-A

dju

ste

d R

ela

tive

Ris

k

Loss of 5-10 kg

Loss or gain of 4.9 kg or less

Gain of 5-6.9 kg

Gain of 7-10.9 kg

Gain of 11-19.9 kg

Gain of 20 kg or more

Diet, lifestyle and the risk of type 2 diabetes mellitus in women

– Risk factors for type 2 diabetes• obesity en weight gain• Physical inactivity, independent of obesity• Low fibre and high GI diet• Specific FA

– Aim• Study the combined effect of these factors

Hu FB, Manson JE et al.

NEJM, 2001; 345:790-7


– Study population• Nurses’ Health Study from 1980-1996• 89 941 patients of total 121 700• Exclusion diabetes, cancer and CV disease

– Dietary-Interview• questionnaire 61 items, semi-quantitive• each diet factor: score 1-5 for the 4 nutrients, dependent

on quintile intake

Hu FB, Manson JE et al. NEJM, 2001; 345:790-7


– Investigation of non-nutrition related factors• Smoking• Menopausal status/substitution• Body weight• Physical activity• Family history of diabetes

NEJM, 2001; 345:790-7Hu FB, Manson JE et al.


– Defining low-risk group (LRG):• BMI<25 kg/m2• Physical activity :30 min/d moderate activity• Smoker : Non-Smoker• alcohol: 0.5U/d• diet: Little trans fat, low glycemic index, high fibre intake,

High ration PUFA

NEJM, 2001; 345:790-7Hu FB, Manson JE et al.


– 16 year follow-up

– diagnose DM according National Diabetes Data Group– Relative risks calculated :

incidence of diabetes in LRGincidence diabetes amongst rest of the women

– ‘population attributable risk’Estimation of the percentage of diabetes type 2 which would not occur if all women were to be placed in the LRG.

Hu FB, Manson JE et al. NEJM, 2001; 345:790-7

Most important risk factor !

61% of new cases DM result of overweight

87 % new cases preventable if all women placed in

LRG

NEJM 2001, 345:790-797

• Conclusion – combination of different factors can prevent Diabetes

• BMI 25

• Diet : high fibre intake; PUFA, Low SFA; trans fats and GI

• Regular physiacl activity

• Non Smoker

• Moderate alcohol use

– incidence of diabetes approx. 90 % lower in this group

– Behavior changes can prevent diabetes

– Most important determinant for DM 2• OVERWEIGHT

BUT

Present prevalence still increasingCurrent therapy strategies not sufficient

– Education Necessary

Risk Factors for Cancers

• Cigarettes/Tobacco

• Betel Nut (lime?)

• Hepatitis B

• Obesity

• Hyperglycaemia


• Dietary Factors– Fat– Fibre– Meat (cooking

methods)– Alcohol– Vegetables and Fruits– Omega 3 fatty acids

Can Johnny come out and eat?

Can physical activity prevent weight gain?

Attenuated weight gain with recreational physical activity: MEN

0

26-39 40-54 55+-26

Baseline weight gain of inactive

Walking

Running

CyclingGolf

NHANES Study, USAAge group

Prospective studies on the effect of physical activity/fitness on long term

weight gain.

• DiPietro et al. 1998 7 yrs *men, *women

• Coakley et al. 1998 4 yrs *men

• Lewis et al. 1998 7 yrs *men, *women• Williamson et al. 1993 10 yrs *men, *women

• Rissanen et al. 1991 5 yrs *men, *women

Estimated relative odds of weight gain category by recreational physical activity: WOMEN

Base-Follow-up

Weight gain category

3-8 kg 8-13 kg >13 kgHi - Hi 1.0 1.0 1.0Med-Med 1.7 1.0 3.4Lo - Lo 2.1 1.5 7.1Increased 1.7 0.9 3.4Decreased 2.4 1.3 6.2

Williamson et al., (1993), IJO, 17, 279-86

00.10.20.30.40.50.60.70.80.9

1

Year1

Year2

Year3

Year4

Year5

Year6

ControlLifestyle

Effects of an Obesity Prevention and Exercise Program on the Development of NIDDM in Men and Women with Impaired Glucose Tolerance

Tuomilehto, et al. NEJM 344:1343-1350, 2001

Percent of Participants Free of Diabetes

P <0.001

58%

80%

0

2

4

6

8

10

12

14

ALL Men Women

Effects of Metformin or Lifestyle Interventions on the Incidence of Developing Diabetes in High Risk Men and Women

Cases per 100 person-years PlaceboMetforminLifestyle

Diabetes Prevention Program Research Group.NEJM,2002:346:393-403

N = 3234Men & women• Overweight• Sedentary• High glucose

PA = 150 min/wWeight - 12 lbs.Metformin = 850 mg 2 x day

2.8 yr. follow-up

Recent natural gas and electric energy shortage may be our salvation inCalifornia.

Eco House at Humbolt State University generates all its power needs via human power generation using cycle ergometers connected to generators.

Reversal of Downward Trend in Daily Physical Activity Will Require Innovative and Integrated Approaches

Integrated Programs to Reduce ObesityIntegrated Programs to Reduce Obesity

Public education via mass media - “set the stage”

Community-based programs for physical activity and nutrition - promote individual behavior change

Environmental change to promote activity - sidewalks, parks, showers @worksites, mall walking, etc.

Policy change to promote activity and healthy eating - schools (PE & recess), worksites, government, etc.

Incentive/penalty programs - health insurance companies: third-party payment can be a disincentive

Spectrum of obesity management

Weight loss has beneficial health effects

• Improved glycaemic control• Reduced blood pressure• Improved lipid profile• 20% reduction in premature mortality in

overweight women with obesity-related health conditions Goldstein DJ. Int J Obesity, 1991

A weight loss of A weight loss of 5% in obese individuals with 5% in obese individuals with comorbid type 2 diabetes, hypertension or comorbid type 2 diabetes, hypertension or dyslipidaemia resulted in:dyslipidaemia resulted in:

Obesity management: objectives

• Promotion of weight loss

• Long-term weight maintenance

• Long-term prevention of weight gain

• Improvement of risk factors

• Encouragement of active lifestyle

• Improvement in quality of life

• Change in eating patterns

THE MANAGEMENT OF OBESITY: AN INTEGRATED APPROACH

• Obesity is a serious medical condition requiring long-term management

• Management needs to be flexible and integrate different therapeutic approaches according to individual patient needs including

– Dietary management

– Lifestyle modification

– Physical activity

– Drug therapy

– Surgery

WEIGHT MANAGEMENTWeight

Keep WeightSlight ReductionModerate Red.(medical useful)

Normalising Weight

(Not realistic and contraproductive)

Weight Gain

Obesity

Overweight

Normal Weight

Years

PATIENT EXPECTATIONS Patient weight

loss goals % patient achieved after intervention

Dream weight -38% 0%

Happy weight -31% 9%

Acceptable weight -25% 24%

Dissappointing weight -17% 20%

Below dissappointing weight 47%

Reference: Foster et al. J Consult Clin Psych 1997; 65(1): 79-81

CONTRASTING PATIENT AND PHYSICIAN EXPECTATIONS

Expectation Patient Physician

Rate of weight loss

Rapid Gradual

Weight loss (% of initial weight)

20% 5-10% (15%)

Time on diet Some weeks Rest of life

Goals Weight loss Cosmetic purposes

Physical fitness

Weight maintenance To decrease obesity co-morbidities

Metabolic fitness

Reference: Ziegler O, Meyer L, Guerci B et al. In press.

And finally, we need to recognize that we do not know how to successfully

“treat” obesity…

The question we need to address is:

How do we help people maintain health in an environment conducive

to people weighing more?

THE NEED FOR REALISTIC GOALS IN OBESITY MANAGEMENT

• Shift focus from changing appearance to improving health

• Consider healthier weight over time - not ideal weight

• Sustained moderate weight loss of 5-10kg (5-10% of initial body weight)

– Elevated BP

– Blood sugar concentrations

– Serum triglycerides

– HDL-cholesterol levels

Long-term management of obesity

• Efficacy of long-term treatment requires– Patient motivation for weight loss– Patient satisfaction with weight loss– Patient satisfaction with treatment

• Best achieved by combination of– Low-fat diet– Increased physical activity– Well-tolerated pharmacotherapy

Lesson 4 : Nutrition Disorders Obesity and health consequences.

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Transcript of Lesson 4 : Nutrition Disorders Obesity and health consequences.