Lesson 4 : Nutrition Disorders Obesity and health consequences

Physical Activity, Calories and Obesity: Physical Activity, Calories and Obesity: The 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 USA England Mauritius Australia Brazil Population percentage with BMI > 30kg/m 2 Obesity rates: current and projected

Collated by the IOTF from recent surveys Yugoslavia Greece Romania Czech Rep. England Finland Germany Scotland Slovakia Portugal Spain Denmark Belgium Sweden France Italy Netherlands Norway Hungary Switzerland % BMI > Male and Female Obesity Levels in Selected European Countries WomenMen

15% 15% Prevalence of Obesity among U.S. Adults, BRFSS, 1990 (BMI > 30) Height Weight 152 (60) 69 (153) 167 (66) 84 (186) 178 (70) 94 (207) BMI = 30

15% 15% Prevalence of Obesity among U.S. Adults, BRFSS, 1991

15% 15% Prevalence of Obesity among U.S. Adults, BRFSS, 1996

15% 15% Prevalence of Obesity among U.S. Adults, BRFSS, 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: Diabetes Trends Among Adults in the U.S., BRFSS % Source: Mokdad et al., Diabetes Care 2000;23:

Diabetes Trends Among Adults in the U.S., BRFSS Source: Mokdad et al., Diabetes Care 2000;23:

Diabetes Trends Among Adults in the U.S., BRFSS 1995 Source: Mokdad et al., Diabetes Care 2000;23:

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 inputEnergy output Control factors Genetic make-up Diet Exercise Basal metabolism Thermogenesis

Aetiology of obesity LIFESTYLE 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 ONSET DIABETES OF THE YOUNG NORMALBASALSTATE HYPERGLYCEMIA SENSED AS EUGLYCEMIA IN MODY NORMALSTIMULATION OF INSULIN SECRETION BY HYPERGLYCEMIA GLUCOSE GLUCOSE HK G6P METABOLITES hk G6P METABOLITES HK G6P METABOLITES GLUCOSE

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

The “Thrifty” Hypothesis FAVORINGENERGYUTILIZATION The Grasshopper FAVORINGENERGYSTORAGE The Ant FEASTFAMINEFEASTFAMINE REPRO-DUCTIVEADVANTAGE DEATH OBESITY/DIABETES SURVIVAL

Normal glucose tolerance Plasma glucose (mg/dl) Time (min) Normal Plasma insulin (uU/ml) Time (min)

Impaired glucose tolerance: Hyperinsulinemia and insulin resistance Plasma glucose (mg/dl) Time (min) Impaired glucose tolerance Normal Plasma insulin (uU/ml) Time (min)

Insulin Resistance in Type 2 DM Glucose Disposal Rate (mg/M2/min) Insulin Concentration (uU/ml) Diabetes Control

INSULIN-STIMULATED GLUCOSE UPTAKE IN MUSCLE AND FAT

UNDERSTANDING TYPE 2 DIABETES LIPIDSCARBOHYDRATE

WHICH IS THE CART AND WHICH IS THE HORSE?

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 predicts type 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

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 controls deprive us from walking! 20 times daily x 20 m = 400 m Walking distance lost/year 400x365 = 146,000 m 146 km = 25 h of walking 1 h of walking = kcal Energy saved = kcal Rössner, 2002 High-Tech increases Body Weight  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 Modern Men Women ∆ = 42% ∆ = 27% Montgomery E., Fed Proceed 37:61-64, 1978

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

“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 Railroad Stephen Ambrose 2000

“Required daily activity” between 1850 and 1950 for many people in technologically advancing societies decreased substantially and this decrease was easily observable. Since the 1950s there has continued to be a decline in “required daily activity” in many societies, but this decrease in more subtle and less well documented. Decline in Daily Required Activity Resulting from the Industrial Revolution the Industrial Revolution

“ These lumberjacks worked hours, six days per week from April through November logging the giant redwood trees. Their primary equipment included 9-pound axes, two-man saws, buck saws, hand winches and wedges.” History of the Sierra Nevada C. Taylor, 1996 Required Daily Activity High for Many Workers 1n 1900

RMR = 1Kcal/Kg/Hr (VO 2 = 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 MENWOMEN RMR Very Light<1.46<1.41 Light Moderate Heavy Exceptional>2.25>2.05 WHO Obesity Guidelines, Technical Report Series 894

Due Variations in Energy Expenditure Due to Daily Physical Activity PAL Kcal/day* RMR Sedentary Moderately Active Very Active 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 voic People movers - escalators Wireless 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 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

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 Poland % time Data from WHO MONICA report, 2000 OccupationalHouseholdRecreationalTransportation OccupationalHouseholdRecreationalTransportation China Italy Poland MENWOMEN

Increased Time at Computer/TV/Video Decreases Time for Leisure-Time Physical Activity >

TVVideo Tapes Video games ComputerMoviesTOTAL years 8-18 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"

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, Technical Report Series 894

Due Variations in Energy Expenditure Due to Daily Physical Activity PAL Kcal/day* BMR Sedentary Moderately Active Very Active Primitive Man Finnish Lumberjacks Light Activity * Kcal/day for 70 kg person WHO GOAL

Due Variations in Energy Expenditure Due to Daily Physical Activity PAL Kcal/day* BMR Sedentary Moderately Active Very Active 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)

Due Variations in Energy Expenditure Due to Daily Physical Activity PAL Kcal/day* BMR Sedentary Moderately Active Very Active 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 size High calorie density Low cost Occupational Transportation Household 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 Has 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 Has Reduced the Cost of High Calorie Low Nutrient Food

Double Cheese Burger = 690 Super Size Coke = 280 Biggie Fries = 570 TOTAL = 1,540 CALORIES 62 grams of fat High Caloric Density Food Always Available at Low Cost Ad in Sports Illustrated 15/06/02

Introduction 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, % Obese Hrs sat/wk

Hourly movement counts of obese and non-obese adults: Weekdays Cooper et al., EJCN, 2000

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

Eat to Live! Live to Eat!

“EAT TO LIVE” Intake = Expenditure Weight Stable “LIVE TO EAT” Intake > Expenditure Obese

Ageing and Energy Expenditure James, Ralph and Ferro-Luzzi, 1989 Kcals/d Intense exercise Occupational Discretionary Sitting, coffee, smoking Basal metabolic rate Dietary induced thermogenesis 70 kg, Aged 25 years 70 kg, Aged 70 years

Fat as the Macronutrient Culprit Adapted from WHO Consultation 1998 ProteinCarbohydrate Fat Energy content per g Ability to end eating Ability to suppress hunger Storage capacity Pathway to transfer excess to alternative compartment Ability to stimulate own oxidation 4 High High Low Yes Excellent 4 Moderate High Low Yes Excellent 9 Low Low High No Poor

Dietary fat Typical Belgian diet Carbohydrate 40–50% Protein 15–20 % Fat 40% Desired Belgian diet Carbohydrate 45–55% Protein 15–20 % Fat 30% Staessen L. et al. : Ann. Nutr. Metab. 1998; 42;

Contribution of fat, protein, carbohydrate and alcohol to the energy intake in the average British diet Energy needs Measurement of Energy Intake

Consequences of obesity

…because of fat infiltration 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 visceral abdominal adipose tissue Insulin resistance and hyperinsulinaemia Atherogenic dyslipidaemia Total-C  LDL-C  HDL-C  Triglycerides  Small, dense LDL  Apolipoprotein-B  Hypertension LVH Congestive heart failure Prothrombotic state PAI-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)

Prevalence of Metabolic Syndrome in Men and WOMEN - USA MEN (24.0%) WOMEN (23.4%) Total = 47 million people NHANES AGE -YEARS Mexican American = 31.9%

Obesity treatment Why? 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 Low (  73.6) Medium ( ) High (  81.8) Waist Circumference tertiles (cm) High (  25.2) Medium ( ) Low (  22.1) BMI tertiles (kg/m 2 ) Age-adjusted CHD incidence/ person-years Rexrode KM et al. JAMA, 1998; 280:

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: Accessed July 31, 1998.

Greatly Increased Moderately increasedSlightly increased (relative risk >>3)(relative risk c. 2-3)(relative risk c. 1-2) DiabetesCoronary heart diseaseCancer (breast cancer in postmenopausal women, endometrial cancer, colon cancer) Gall bladder diseaseHypertensionReproductive hormone abnormalities DyslipidaemiaOsteoarthritis (knees)Polycystic ovary syndrome Insulin resistanceHyperuricaemia and gout Impaired fertility BreathlessnessFetal defects arising from maternal obesity Sleep apnoeaLow 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 cancer Wolf et al. Obes Res. 1998;6: % 17% 30% 14% 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: *BMI  27.3 mg/m 2 for women;  27.8 kg/m 2 for men

Type 2 Diabetes in the Pediatric Population: First Nation Data

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:

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:

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:

Link Between Obesity and Type 2 Diabetes: Nurses’ Health Study Colditz GA, et al. Ann Intern Med. 1995;122:

Adapted from Chan JM et al. Diabetes Care 1994; 17: Colditz et al. Ann Intern Med 1995; 122: a Age-adjusted relative 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:

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 patients of total 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; 345:790-7 Hu 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; 345:790-7 Hu 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 LRG incidence 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:

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 increasing Current 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 Baseline weight gain of inactive Walking Running Cycling Golf NHANES Study, USA Age group

Prospective studies on the effect of physical activity/fitness on long term weight gain. DiPietro et al yrs *men, *women Coakley et al yrs *men Lewis et al yrs *men, *women Williamson et al yrs *men, *women Rissanen et al yrs *men, *women

Estimated relative odds of weight gain category by recreational physical activity: WOMEN Williamson et al., (1993), IJO, 17,

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: , 2001 Percent of Participants Free of Diabetes P < % 80%

Effects of Metformin or Lifestyle Interventions on the Incidence of Developing Diabetes in High Risk Men and Women Cases per 100 person-years Placebo Metformin Lifestyle Diabetes Prevention Program Research Group.NEJM,2002:346: N = 3234 Men & women Overweight Sedentary High glucose PA = 150 min/w Weight - 12 lbs. Metformin = 850 mg 2 x day 2.8 yr. follow-up

Recent natural gas and electric energy shortage may be our salvation in California. 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 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, 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  5% in obese individuals with comorbid type 2 diabetes, hypertension or 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 MANAGEMENT Weight Keep Weight Slight Reduction Moderate Red. (medical useful) Normalising Weight (Not realistic and contraproductive) Weight Gain Obesity Overweight Normal Weight Years

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

CONTRASTING PATIENT AND PHYSICIAN EXPECTATIONS 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