1. Caroline M. Apovian, MD, FACN, FACP Director, Nutrition & Weight Management Center Boston Medical Center September 21, 2011 What’s NEW in NUTRITION

2. Public Health Crisis 2 165 Million Americans will be obese by 2030 165 Million Americans will be obese by 2030 50% of Men 45-52% of Women

3. Rising Prevalence of Obesity Increases burden on the health of populations, healthcare systems and overall economies Leads to millions of additional cases of diabetes, heart disease, stroke, and cancer Major challenge for researchers is to quantify the effect of these burdens to inform public policies 3 Wang YC, et al. Lancet 2011;378(9793):815 – 825.

4. NIH Clinical Guidelines, September 1998 Body Mass Index (BMI) Defines Obesity Measure of weight in relation to height Formula: weight (lb) x 703  height (in) 2 4

5. Projected Effects of Improvement US population level decrease in BMI by 1% would avoid as many as: – 2.4 million cases of diabetes – 1.7 million cases of heart disease and stroke – Up to 127,000 cases of cancer 5 Wang YC, et al. Lancet 2011;378(9793):815 – 825.

6. What Can Be Done?

7. Food Guide Pyramid 7 2005 Updated Too complex 2011 Replacement Understandable, practical icon guides eating choices 1992 Introduced by USDA Minimal impact

8. ChooseMyPlate.gov – Basic Principles 8 ½ Fruits and Vegetables ¼ Grains and ¼ Protein Dairy Foods

9. ChooseMyPlate.gov – Features Look up a food Learn about food groups Get a personalized Plan Learn healthy eating tips Get weight loss information Plan a healthy menu Analyze my diet Get MyPlate updates Ask a question http://www.choosemyplate.gov/ 9

10. Help reduce obesity rates Impact depends on size of your plate Portion sizes still matter Many dieticians recommend use of a 9-inch plate 10 ChooseMyPlate.gov – Goal

11. Etiology of Obesity – New Focus Recent focus on the contribution of individual bacterial species and microbial communities – Precipitated by change from culture-based techniques to genetic analysis (metagenomics) Majority of intestinal organisms not able to be cultured Tennyson and Friedman. Microecology, obesity and probiotics. Endo, Diabetes & Obesity 2008, 15:422-427. 11

12. New Obesity Treatments? Recent evidence suggests: – Gut microbiota is critical for maintaining normal gastrointestinal and immune function, and normal digestion of nutrients – Obese and lean people have different gut microbiota Gut microbiota may play important role in regulating weight and be partly responsible for development of obesity in some people New studies are investigating manipulation of gut microbiota using probiotics, antibiotics, and /or prebiotics as a treatment for obesity Tennyson and Friedman. Microecology, obesity and probiotics. Endo, Diabetes & Obesity 2008, 15:422-427. 12

13. Metagenomics Tennyson and Friedman. Microecology, obesity and probiotics. Endo, Diabetes & Obesity 2008, 15:422-427. Term used for cloning and analysis of microbial DNA using culture- independent techniques – DNA elucidates organism profiles and is a tool to explore function of heterogeneous communities Samples obtained from feces and mucosal biopsies are used to study luminal and/or mucosal communities 13

14. Metagenomics Adult human gut contains up to 100 trillion microbial organisms (mostly anaerobic) – These microbiota contain 500-1000 bacterial species – and ~100x the number of genes found in the human genome – More recent research indicates 18,000 genera and 15,000–36,000 bacterial species Mayo Clinic Proceedings April 2008 vol. 83 no. 4 460-469. 14

15. Metagenomics Human Gut Microbiome Initiative – Effort to sequence gut genomes – http://genome.wustl.edu Macfarlane S, Macfarlane GT. Bacterial diversity in the human gut. Adv Appl Microbiol. 2004;54:261-289. 15

16. Key Physiologic and Microbiological Features of the Gut Relative concentrations of bacteria and pH at various locations http://mayoclinproc.highwire.org/content/83/4/460.figures-only cfu = colony-forming unit Higher bacteria count More anaerobic Less bacteria count More aerobic 16

17. Gut Microbiota in Infants Type of birth delivery has significant impact on development of gut microbiota 1 – Based on vaginal exposure, neonatal care, breast feeding and conversion to adult microbiota following weaning Differences in infant fecal microbiota composition may predispose to obesity later in childhood 2 Children who were overweight at 7 years had lower bifodobacterial concentrations and higher staphylococcus aureus during infancy 1.Mountzouris KC, McCartney AL, Gibson GR. Br J Nutr 2002;87:405-420. 2.Kalliomaki M, et al. Am J ClinNutr 2008; 87:534-538. 17

18. Mayo Clinic Proceedings April 2008 vol. 83 no. 4 460-469. Major Bacteria and Archaea Phyla and Genera Found in Human Gut Microbiota Account for more than 90% of all phylotypes of bacteria 18

19. Obesity and GI Flora Firmicutes vs. Bacteroidetes – Trillions of bacteria that normally reside within the human GI tract affect nutrient acquisition and energy regulation, and obese and leans have different gut microbiomes – GI tract in obesity has relatively more Firmucutes species than Bacteroidetes, which can be reversed with caloric reduction and weight loss (Gordon) 19

20. Gut Microbiota Composition in Obese Humans Study monitored fecal gut microbiota in 12 obese participants in weight-loss program for 1 year; randomly assigned to fat-restricted or carbohydrate-restricted low- calorie diet Before diet, obese participants had fewer Bacteroidetes (3%) and more Firmicutes than lean controls; post weight loss, Bacteroidetes increased to 15% and Firmicutes decreased Ley RE, Turnbaugh PJ, Klein S, Gordon JI. Nature. 2006;444(7122):1022-1023.  Bacteroidetes  Firmicutes  Bacteroidetes  Firmicutes 20

21. Microbiota and Inflammation LPS* is triggering factor linking inflammation to high fat diets and metabolic syndrome Type II diabetics have higher LPS levels than those without DM Creely SJ, et al. Am J Physiol Endocrinol Metab 2007; 292:E740-E747. *LPS = Lipopolysaccharide 21

22. Human Microbiome Project: NIH Do humans share a core human microbiome? Can changes in the microbiome correlate with changes in human health? What is the technology required to answer these questions? http://nihroadmap.nih.gov/hmp/ Microbiome and Disease: NIH Priority 22

23. The Future is Here Autom™ Weight Loss Coach Creates an ongoing, supportive relationship with a user through daily conversations that evolve over time Designed to motivate a user to stick with their diet for much longer than existing weight loss solutions 23 http://www.intuitiveautomata.com/products.html

24. Background Research Autom™ was shown to keep people on a diet program for significantly longer than two control groups, one using a computer with identical software and another with a traditional paper log Study based at Boston Medical and the MIT Media Lab Autom™ by Intuitive Automata Inc. 24

25. Offers a short conversation daily to help track eating and exercise - quickly and simply Provides motivation through feedback, advice, and encouragement No two conversations are alike Adapts to specific needs and daily activities Keeps track of what works A randomized, controlled medical study showed that individuals using Autom™ to help keep with their diet were much more successful than those who used more traditional methods, like a paper log or a computer program 25 Autom™ by Intuitive Automata Inc.

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27. Conclusion Obesity is on the rise causing an enormous public health issue New nutrition innovations: – Choosemyplate.gov: eat less and avoid oversized portions – Probiotics research: unveiling important information – Robotics: motivation and accountability A decrease in BMI by 1% would spare millions from disease 27

28. Resources 28

29. 45–65% of calories from CARBOHYDRATES 20-35% of calories from FAT 10-35% of calories from PROTEIN -14 grams per 1000 calories intake Total FIBER -25 grams women (50 yrs and younger) -21 grams women (over 50 yrs) WATER: 2.7 liters (91 ounces) total water from all beverages and foods 2 1.http://fnic.nal.usda.gov/nal_display/index.php?info_center=4&tax_level=3&tax_subject=256&topic_id=1342&level3_id=5140 2.http://www.iom.edu/?id=24805 National Academies' Institute of Medicine Dietary Reference Intakes (DRI) Recommendations for Healthy Eating 29

30. Calcium1200 mg/d Vitamin D 1000 IU 2,3 (2010 recommendations lower: most Americans and Canadians up to age 70 need no more than 600 international units of vitamin D per day 5 ) Phosphorus 4 g/d Folate1000 ug/d Magnesium 350 mg/d Potassium2000 mg (bananas, apricots, salmon) Omega 3.5 – 1.8 g/d 4 (fatty fish or supplements) 1.http://fnic.nal.usda.gov/nal_display/index.php?info_center=4&tax_level=3&tax_subject=256&topic_id=1342&level3_id=5140 2.Holick MF. The role of vitamin D for bone health and fracture prevention. Curr Osteoporos Rep. 2006 Sep;4(3):96-102. Review. 3.Holick MF. Vitamin D: importance in the prevention of cancers, type 1 diabetes, heart disease, and osteoporosis. Am J Clin Nutr. 2004 Mar;79(3):362-71. Review. Erratum in: Am J Clin Nutr. 2004 May;79(5):890. 4.http://circ.ahajournals.org/cgi/reprint/106/21/2747http://circ.ahajournals.org/cgi/reprint/106/21/2747 5.http://www.iom.edu/Reports/2010/Dietary-Reference-Intakes-for-Calcium-and-Vitamin-D.aspx National Academies' Institute of Medicine Dietary Reference Intakes (DRI) Recommendations for Healthy Eating 30

31. The Practical Guide, October 2000 www.nhlbi.nih.gov The Evidence Report, June 1998 www.nhlbi.nih.gov Assessment and Management of Adult Obesity: A Primer for Physicians www. ama-assn.org/ ama/pub/category/10931.html Weight Management Resources 31

32. Nutrition Resources for Women “Strong Women Stay Young” by Miriam Nelson http://www.strongwomen.com/books/ http://www.womenshealth.gov/faq/overweight-weight-loss.cfm http://www.healthywomen.org/condition/obesity 32

33. Caroline M. Apovian, MD, FACP, FACN Professor of Medicine and Pediatrics Boston University School of Medicine Director, Center for Nutrition and Weight Management Boston Medical Center 88 East Newton Street Robinson Bldg. Suite 4400 Boston, MA 02118 tel: 617 638-8556 fax:617 638-8599 Caroline.Apovian@bmc.org Slide design and development by Susan Morreale, Belmont, MA