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%
Prevalence of Obesity Prevalence of Obesity among U.S. Adults, among U.S. Adults, BRFSS, 1991BRFSS, 1991
<10% 10-15%<10% 10-15% >15% >15%
Prevalence of Obesity Prevalence of Obesity among U.S. Adults, among U.S. Adults, BRFSS, 1996BRFSS, 1996
<10%<10% 10-15% 10-15% >15%>15%
Prevalence of Obesity Prevalence of Obesity among U.S. Adults, among U.S. Adults, BRFSS, 1999BRFSS, 1999
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%
Source: Mokdad et al., Diabetes Care 2000;23:1278-83.
Diabetes Trends Among Adults in the U.S., BRFSS 1991-92
Source: Mokdad et al., Diabetes Care 2000;23:1278-83.
Diabetes Trends Among Adults in the U.S., BRFSS 1995
Source: Mokdad et al., Diabetes Care 2000;23:1278-83.
Source: Mokdad et al., J Am Med Assoc 2001;286(10).
Diabetes Trends Among Adults in the U.S., BRFSS 2000
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
METABOLITESMETABOLITES
HKHK
G6PG6P
METABOLITESMETABOLITES
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
Time (min)Time (min)
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
Time (min)Time (min)
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
Time (min)Time (min)
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
70 kg body weight = 70 x 24 = 1680 Kcal/day
100 kg body weight = 100 x 24 = 2400 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
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
BMR
Sedentary Moderately Active
VeryActive
Primitive Man
Finnish Lumberjacks
Light Activity
* Kcal/day for 70 kg person
WHO GOAL
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 1.52 1.75 2.00 2.65 2.80Kcal/day* 1680 2184 2553 2940 3360 4550 4800
BMR
Sedentary Moderately Active
VeryActive
Primitive Man
Finnish Lumberjacks
Light Activity
* Kcal/day for 70 kg person
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
Variations in Energy Expenditure DueDue to Daily Physical Activity
PAL 1.0 1.30 1.52 1.75 2.00 2.65 2.80Kcal/day* 1680 2184 2553 2940 3360 4550 4800
BMR
Sedentary Moderately Active
VeryActive
Primitive Man
Finnish Lumberjacks
Light Activity
* Kcal/day for 70 kg person
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
Obesity : Definition
• 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
Obesity : Definition
• 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
• Physical Activity
• 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
Prevalence of impaired glucose tolerance among children and adolescents with marked
obesity
Results• 25 % IGT in children (4-10y)• 21 % IGT in adolescents (11-18y)• Increased insulin values in IGT• 4 % insidous DM2 in adolescents
Sinha R, Fish G et al. NEJM 2002; 346: 802-10
Prevalence of impaired glucose tolerance among children and adolescents with marked
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
Sinha R, Fish G et al. NEJM 2002; 346: 802-10
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
Diet, lifestyle and the risk of type 2 diabetes mellitus in women
– 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
Diet, lifestyle and the risk of type 2 diabetes mellitus in women
– 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.
Diet, lifestyle and the risk of type 2 diabetes mellitus in women
– 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.
Diet, lifestyle and the risk of type 2 diabetes mellitus in women
– 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
• Physical Activity
• 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