1. FANUS Conference
Abuja, Nigeria 2011
The Obesity Epidemic
Pilar Riobo , MD, PhD
Madrid , Spain

3. Today discussion points
• Prevalence and Metabolic Syndrome
• Causes of obesity
– Excessive Caloric intake
– Psychological factors (binge eating, nocturnal eating synd)
– Social factors:
 Excesive TV watching and videogames
 Family meals protective
 No breastfeeding
 Short sleep duration
 Light during night time
 Friends and environment
– Female obesity
– Communication oportunities in nutrition

4. The Rising
Rate of
Childhood
Obesity is
Alarming
30% of children are overweight
or at risk for overweight

5. Obesity Today: Future Impact
“Because of increasing rates of
obesity…we may see the first
generation that will be less healthy
and have a shorter life expectancy
than their parents.”
Surgeon General Richard Carmona

6. Prevalence of obesity in children
in granada, spain
González Jiménez, et al. Nutr Hosp 2011

7. ALADINO STUDY. SPAIN
6-10 years old children

8. Prevalence of overweight and obesity
in European countries
Where is the mediterranean diet?

9. Relation between BMI and chronic
diseases (NHS and PHS)
Type 2 diabetes Cholelithiasis Hypertension Coronary heart disease
Women Men
6
5
Relative Risk
4
3
2
1
0
<21 22 23 24 25 26 27 28 29 30 <21 22 23 24 25 26 27 28 29 30
Body Mass Index (kg/m2) Body Mass Index (kg/m2)
Willett WC, et al. N Engl J Med. 1999;341:427–434.

10. Obesity and overweight have been reported to be
associated with large decreases in life expectancy.
Non-smoking women Smoking women Non-smoking men Smoking men
Framingham Heart Study
13.7
Non-smoking women lost 7 years,
5.82 Non-smoking men 5.8 years
13.3
7.08
0 5 10 15
Implications of obesity at age 40 on life expectancy.
Peeters, A, et al. Ann Int Med 2003;138:24-32.

11. Obesity is associated with increased risk
for most cancers
1.44
Multiple myeloma (>35)
1.46
Colon & Rectum (>40)
Type of Cancer (Highest BMI category)
1.51
Ovary (>35)
1.68
Liver (>35)
1.88
All Cancers (>40)
1.95
Non-Hodgkin’s Lymphoma (>35)
2.12
Breast (>40)
2.13
Gallbladder (>30)
2.51*
All Other Cancers (>40)
2.64*
Oesophagus (>30)
2.76
Pancreas (>40)
3.20
Cervix (>35)
4.75
Kidney (>40)
6.25
Uterus (>40)
0 1 2 3 4 5 6 7 8 9 10 11
Relative Risk of Death (95% Confidence Interval)
Calle E et al. N Engl J Med 2003;348:1625-1638
Mortality from Cancer According to BMI >30->40 for U.S.
Women in the Cancer Prevention Study II, 1982 through 1998

12. Risk of Alzheimer’s disease (AD) in elderly
with and without metabolic syndrome
980 elderly subjects (337 male,622 female; 69-78) 13 cases AD in men 32 in women
With metabolic syndrome Without metabolic syndrome
9 P<0.001
Prevalence Alzheimer's disease (%)
8
7
6
5
4
3
2
1
0
Women Men
Vanhanen M, et al. Neurology 2006.67:843-47
Increased risk for cognitive dysfunction and dementia in elder women

17. Obesity and other risk factors
Blood HDL-C PCRP
pressure
pro-thrombotic
T-Cholesterol-t OBESITY factors
Insulín
Diabetes Resistance
TG,Lp(a)
sdLDL

18. Hypertension and Obesity
Direct and lineal relationship
20 25 30 35 40
IMC
Prevalence10.6% (BMI<20), 13.3% (BMI 20-25), 22.8% (BMI 30-40) y 61.3% (BMI>40).
Australian Longitudinal Study on Women’s Health
Brown WJ et al. Int J Obes 1998;22:520-528.

19. Diabetes and Obesity
20 25 30 35 40
IMC
Brown WJ et al. Int J Obes 1998;22:520-528.

21. ATP III Criteria for Identification of the Metabolic Syndrome
Abdominal obesity (waist circumference)
Men >102 cm
Women >88 cm
Triglycerides 150 mg/dL
HDL cholesterol
Men <40 mg/dL
Women <50 mg/dL
Blood pressure >130 / 85 mm Hg
Fasting glucose >110 mg/dL
Diagnosis of the metabolic syndrome is made when 3 or more of the risk
determinants shown above are present.

22. How Common is the Metabolic
Syndrome?
• 24% all adults
• 42% over age 60 yrs

23. But....,
…individuals who are genetically
predisposed to insulin resistance may
forestall or even prevent the development
of diabetes by staying thin and physically
active.

24. What’s the Cause of Obesity?
There is sometimes a tendency to focus
on one specific CAUSE ….
But…
…there’s no simple answer to this
complex issue…

25. The Biological Cause of
Obesity is Simple
An imbalance of calories IN
and calories OUT!
But…

26. …The Social Factors that lead to
the Imbalance are Complex
• Changing food habits due to busy lifestyles
• Declining physical activity during work and
leisure time
• Changing physical environment (urban, safety)
• Decreased sleep duration
• Hedonic and reward aspects of food
• Psychological problems
• Side effects of common drugs

27. Weight Issues
It’s Much More than
ENERGY BALANCE
Social factors play a role

28. Popularity of low-carb diets that 28
blame carbohydrates and sugar for everything
?

30. Low-carb, high-protein, high-fat vs.
conventional hypocaloric diet
PRCT, 63 obese
Low-carb lost more
weight at 3 and 6
months but was
similar at 12 months
Foster GD et al. N Engl J Med 2003; 48:2082-2090

31. CARMEN Study .
investigated the effects of replacing one-quarter
of daily fat intake by complex or simple CH
Energy intake was ad libitum
A low-fat, high-polysaccharide
diet led to long-term moderate
weight loss and improved serum
cholesterol
Increasing simple carbohydrates
did not promote weight gain
Poppitt S D et al. Am J Clin Nutr 2002;75:11-20

32. 18000 U.S. male physicians
reported measures of breakfast,
cereal intake, weight
After13 years of follow-up,
BMI and weight gain were inversely
associated
with intake of breakfast cereals,
independently of other risk
factors.
Obes Res. 2005; 13:1952–1960

33. Fructose intake correlates closely
with the rate of diabetes worldwide
Bray GA. Consumption of high-fructose corn syrup in beverages may play a role in the epidemic of
obesity. Am J Clin Nutr 2004; 79: 537-543.

34. Could Excessive Fructose Intake (>50 g/d)
cause metabolic syndrome?
The primary sources of fructose are table sugar (sucrose)
and high fructose corn syrup.
Unlike other sugars, the ingestion of excessive fructose
induces features of metabolic syndrome in laboratory
animals
Fructose appears to mediate the metabolic syndrome in
part by raising uric acid

35. Could Excessive Fructose Intake and Uric
Acid Cause Type 2 Diabetes?

36. Fat makes us fat??
Direct relationship between fat intake and weight:
Higher caloric content/gram
Difficult oxidation compared to carbs
(Carbs are inmediatly oxidated)
Higher palatability promotes increased
consumption

37. Psychological problems
severe depression in 32%
suicidal risk in 23%.
Anxiety : 50%
Binge eating disorder (BED) : 1–4% of general
population and about 30% of obese subjects
attending weight control programs
Night Eating Syndrome (NES) : morning anorexia,
evening hyperphagia, and insomnia with awakenings
followed by nocturnal food ingestion.
Lester D. Depression and suicidality in obese patients. Psychol Rep.2011:108(2):367-8.

38. Psycohological problems at first visit
assessment of patients at obesity clinic:
• Elevated scores for depression in 48%
• Elevated scores for anxiety in 56%
• Personality trait overlapping with eating disorders
in 22%
• Elevated scores for bulimia in 11.5%
• Significant impairment in quality of life in 30%
A Tuthill et al. Q J Med, 2006: 9

39. Neurobiological mechanisms underlying food intake
Brain dopamine, which regulates motivation for food intake,
is likely to be involved
Obese individuals overeat to compensate for a reward deficit
Have fewer striatal D2 receptors and show less striatal response to
palatable food intake
Coronal section showing less activation in the right caudate in the weight-gain group versus the weight-
stable group during milkshake receipt–tasteless intake
Stice E et al. J. Neurosci. 2010;30:13105-13109

40. Short sleep and sleep abnormalities
244 children, age 3 to 7.
Each additional hour of sleep at ages 3-5
was associated with a
reduction in BMI of 0.48
and a reduced risk of being overweight of 0.39

41. After 32 years follow-up, shorter childhood sleep times
were significantly associated with higher adult BMI

42. The potential mechanisms through which short
sleep duration could result in obesity.
Taheri S Arch Dis Child 2006;91:881-884

43. Weight gain as side effect of
drugs
Anti-depresants and psychotropic
Anti-histaminics
Corticoids
Beta-blockers
Contraceptives
........

44. Antipsychotic drugs
After a median of 11weeks treatment, weight
increased by:
8.5 kg with conventional antipsychotic drugs
6.1 kg with quetiapine
5.3 kg with risperidone
4.4 kg with aripiprazole
Correl et al. JAMA, 2009;302:16 1765

45. Contraceptives
Daily energy intake was higher
and resting metabolic rate was lower
in both follicular and luteal phases
after medroxyprogesterone
compared with placebo

46. Prolonged breast-feeding protects mothers
from later-life obesity
20 years after their last pregnancy,
women who had breast-fed for
less than 6 months had higher fat mass
percentage, than mothers who had
breast-fed for longer than 6 months
But rates of breast feeding are low
Wiklund P et al. Public Health Nutr. 2011;23:1-8

47. Frequency of Shared Family Meals
sharing 3 or more family meals per week reduces odds
overweight (12%),
eating disorders (35%)
Pediatrics 2011;127:e1565

48. Light at night increases body mass in mice
• compared with mice in a standard light/dark cycle,
• despite equivalent levels of caloric intake and total daily
activity output.
• Nocturnal rodents typically eat substantially more food at night
Exposure to nighttime lighting and the resulting
changes in the daily pattern of food intake and activity
also may be contributing factors to obesity pandemic ??
Fonken LK. Proc Natl Acad Sci. 2010; 26:18664-9.

49. Activity Level and Risk of Overweight
Professionals Health Study
Men watching 21 or more hours of TV per week were over 40% more likely to
become overweight than were men viewing 1 hour per week
Ching P. Am J Public Health 1996

50. The increased time spent in sedentary screen-based
activities has also been implicated as contributing to
overweight and obesity
.

51. Television (TV) viewing:
the dominant recreational pastime at all ages
Higher TV viewing hours are associated
- higher body mass index (BMI),
- lower levels of fitness
- higher blood cholesterol levels.
Potential mediators of the effect:
- less time for physical activity
- reduced resting metabolic rate
- increased energy intake (eating while watching TV
and exposure to marketing of energy dense foods).

52. Children who watched the most television during childhood had the
greatest increase in body fat over time
By age 11, children who watched 3.0 h or more television per day
had a mean sum of skinfolds higher (106.2mm, vs 76.5mm) than
those who watched less than 2 per day

53. 70 children randomized to reduce
their television viewing and computer use by 50% vs control
In the intervention group, reductions in BMI and
energy intake were shown
Epstein. ARCH PEDIATR ADOLESC MED/ 2008

54. 70 children randomized to an intervention to reduce
their television viewing and computer use by 50% vs control
Reducing television viewing and computer
use may have an important role in
preventing childhood obesity
In the intervention group, reductions in BMI
and energy intake were shown
Epstein. ARCH PEDIATR ADOLESC MED/ 2008

55. Effects of active video games on body composition
a randomized controlled trial
BMI from baseline, at 24 wk
control group increased 0.34
intervention group reduction−0.24
change in BMI by ethnic subgroup].
Small but definite effect on BMI and body composition
in overweight and obese children at 24 wk
Maddison R et al. Am J Clin Nutr 2011;94:156-163

56. Friends
Framingham Heart Study cohort
Among married couples, when an alter became obese, the spouse was 37% more
likely to become obese.
If an ego stated that an alter was his friend, the ego’s chances of becoming obese
increase by 57% if the alter became obese.
Between mutual friends, the ego’s risk of obesity increased by 171%

57. Having obese social contacts might lead to
adopt specific behaviors
Could obesity be considered contagious???

58. Female obesity
rates of obesity
are higher in
Effects during
women pregnancy on
offspring
Metabolic effects
during pregnancy
In an obesogenic environment, women are at greater risk for obesity
.
Transgenerational issues: Nutrition during fetal and early life can influence risk
for obesity on offspring

59. Obesity and pregnancy
Medical Complications Technical Complications
Early Miscarriage
Difficult ultrasound
pregnancy Twinning
 pregnancy induced hypertension GDM occurs in ~4% of pregnancies
 pre-eclampsia
Antenatal  gestational diabetes
Overweight women have 17% risk
 venous thromboembolism
Higher rates for
 induction of labor Operative: higher rates c-section
Intrapartum  planned and acute c-section infection, bleeding and thrombosis
 assisted delivery Anesthesia
 vaginal tears
Postpartum Macrosomia, congenital
Hemorrhage, infection, venous thromboembolism
Fetal abnormalities, fetal distress, Birth injury
Macrosomia, morbidity and mortality
perinatal congenital abnormalities, fetal
Fetal distress, perinatal morbidity and mortality
Birth injury

60. Body Mass Index predicts infertility in women
with and without PCOS
4.0
3.5 With PCOS
3.0
Relative Risk
2.5
2.0
1.5
1.0
0.5
Without PCOS
0
<16 16-17.9 18-19.9 20-21.0 22-23.9 24-25.9 26-27.9 28-29.9 30-31.9 >32 35
BMI at Age 18
Adapted from Rich-Edwards JW, Goldman MB, Willett WC, et al.
Am J Obstet Gynecol 1994;171:171-7

61. Diabetes epidemic
300
300 millions
250
Millones de personas
200
135 millions
150
154 millionsio
100
50
0
1995 2000 2025
King H. Diabetes Care 1998

62. Increasing Prevalence of Diabetes
from 1990 to 2000

64. Insulin Resistance:
A Primary Factor in Type 2 Diabetes
– Condition in which greater than normal amounts of
insulin are required to produce
a normal biological response
Olefsky JM. In: Ellenberg and Rifkin’s Diabetes Mellitus. 5th ed. 1997:513-552.

66. Diabetes Mellitus
Health Impact of the Disease
6th leading cause of
death
Renal Life expectancy
failure* 5 to 10 yr
Blindness* Cardiovascular
Diabetes disease 2X to 4X
Nerve damage in
Amputation* 60% to 70% of patients
*Diabetes is the no. 1 cause of renal failure, new cases of blindness, and nontraumatic amputations
Diabetes Statistics. October 1995 (updated 1997). NIDDK publication NIH 96-3926.
Harris MI. In: Diabetes in America. 2nd ed. 1995:1-13.

67. Decreased sleep duration or quality may
increase diabetes risk
Selective suppression
of SWS, without any
change in total sleep
time, results
in marked decreases
in insulin sensitivity,
leading to reduced
glucose
tolerance and
increased diabetes
risk
Tasali et al. Slow-wave sleep and the risk of type 2 diabetes in humans PNAS, 2008; 105 1044–1049

68. Diabetes prevention studies
• Malmo Preventive Trial withDiet&Exercise
• DaQuing IGT
• Orlistat
• SOS (Swedish Obese Subjects)
• Finnish Diabetes Prevention
• Diabetes Prevention Program
• TRIPOD
• STOP-NIDDM

70. EXERCISE IS GOOD
MEDICINE

71. But, changing habits is not easy

72. So, it’s critical that nutrition communicators help
people and provide motivating tips so they can
adopt more healthful habits

73. But consumers are
confused
about who and what to
believe when it comes to
nutrition …

74. Many people find it
Consumers are difficult to separate
bombarded with Web valid
nutrition Food Sites TV and recommendations
Radio
information from Labels News from fad diet advice.
a variety of
sources. Popular Medical
Magazines
Consumer
Experts
Media Fad
Diet
Nutrition
Images Gurus
information is
Friends
and
Food often seen as
contradictory,
Family Gov’t
Guidelines Ads even from
equally valid
SOURCE: IFIC Foundation, 2004 sources.

75. Most Popular Sources of Food
and Nutrition Information
• Television 62%
• Magazines 48%
• Newspapers 33%
• Internet 23%
• diet books 19%
The information consumers encounter each day is filled
with messages that are often conflicting … and confusing
Difficult for consumers to determine WHO and WHAT is credible

76. The difficult relationship
doctors-journalists
...”Never even whisper to a reporter
anything you would not care to see
in screaming headlines”...
N Engl J Med, 1983

81. A Golden Opportunity for Health
Professionals
Nutrition Sources Rated “Very Valuable” by consumers
Doctors 92%
Registered dietitians 90%
Nutritionists 90%
Magazines 87%
Nurses 85%
Newspapers 82%
TV news 79%
Family and friends 69%
Radio news 65%
Other non-news TV 61%
Internet 61%
ADA Trends Survey 2000 0% 20% 40% 60% 80% 100%

82. Thank you for your attention