Obesity, MetS, diabetes.pdf

Diet-disease interaction: obesity, metabolic syndrome and diabetes Pr. Roberta FORESTI Professor of Biochemistry, Faculty of Health, UPEC [email protected]  Obesity Ideal body weig...

Diet-disease interaction: obesity, metabolic syndrome and diabetes Pr. Roberta FORESTI Professor of Biochemistry, Faculty of Health, UPEC [email protected]  Obesity Ideal body weight: the body weight associated with the highest statistical life expectancy. Used by insurance companies!! Depends on: Weight relative to height Sex, frame size, age BODY MASS INDEX (BMI) weight/(height)2 Normal 18.5-24.9 (< 18.5=undernourished, < 16 severely undernourished) Overweight 25-29.9 Obese class I 30-34.9 Obese class II 35-39.9 Morbidly obese III > 40  Is BMI a meaningful definition of obesity? BMI is easy to measure Separate norms should be used for men, women, children and for different races Does not distinguish fat from lean muscle mass Fat mass and site of deposition are critical determinants of disease risk associated with obesity Over half of adults in the EU are overweight The problem is more pronounced in women than men Effect of social class Economics Higher incidence is associated with Accessibility to shops poverty and low socioeconomic status Media Local culture Attitudes to healthy eating Attitudes to exercise Publié le 21.02.23 Près d’un Français sur deux en surpoids Une étude, coordonnée par des chercheurs de l’Inserm et du CHU de Montpellier, révèle que près d’un adulte français sur deux est aujourd’hui en situation de surpoids ou d’obésité. L’étude, publiée dans le Journal of Clinical Medicine, constate que 47,3 % des adultes français étaient en excès de poids (surpoids et obésité), dont 17 % en situation d’obésité, en 2020. Si on compare ces chiffres à ceux des précédentes études, en l’occurrence la série d’enquêtes Obépi-Roche réalisées tous les trois ans de 1997 à 2012, la population en surpoids fluctue toujours autour de 30 %, tandis que le pourcentage de personnes souffrant d’obésité croît rapidement : il a doublé en un peu plus de deux décennies, passant de 8,5 % en 1997 à 17 % en 2020. Contrairement aux espoirs « tant des pouvoirs publics que des professionnels de santé, depuis la mise en œuvre du Programme national nutrition santé en 2001, l’obésité en France ne fait que s’accroître, année après année », soulignent dans un communiqué Annick Fontbonne, chercheuse épidémiologiste à l’Inserm, et David Nocca, médecin au CHU de Montpellier, qui ont dirigé l’étude. Et l’étude ne prend pas en compte toute la période Covid-19, qui risque aussi d’avoir eu des impacts négatifs sur la santé des Français, liés notamment au manque d’activité physique. Les plus âgés sont plus touchés, l’obésité concernant 19,9 % des 65 ans et plus, contre 9,2 % des 18–24 ans. « La tendance à la hausse a été particulièrement marquée pour le groupe d’âge le plus jeune », souligne toutefois l’étude : depuis 1997 en effet, l’obésité chez les 18–24 ans a été multipliée par plus de quatre. L’obésité connaît « une augmentation qui est forte dans les classes d’âge les plus jeunes », a résumé Annick Fontbonne, lors d’une conférence de presse. Lire le dossier du 20/02/2023 : « Obésité et surpoids : près d’un Français sur deux concerné » Inserm newsletter  France Evolution of the prevalence of obesity by age groups between the 1997-2012 Obépi-Roche surveys and the 2020 Obépi survey. In 2020  Trends in Obesity among Adults and Youth in the United States Adults Youth Trends in age-adjusted obesity and severe obesity Trends in obesity among children and adolescents prevalence among adults ages 20 and over: United ages 2–19 years, by age: United States, 1963–1965 States, 1999–2000 through 2017–20187 through 2017–20183 Obesity and mortality risk  Obesity predisposes to…….  Metabolic syndrome  Type 2 diabetes (T2D)  Hyperlipidemia  Vascular disease  Increased risk of accident  Increased peri-operative risks  Gallstones  Arthritis  Some forms of cancer  Obesity: relationship between BMI and cardiovascular disease or T2D Overweight and obesity were strongly associated with Diabetes risk is greater at lower BMI thresholds and at younger ages increased cardiovascular mortality in adulthood than reflected in currently used BMI cutoffs for assessing diabetes risk. These findings offer an important insight for diabetes screening guidelines.  Key points Obesity prevalence has increased in pandemic dimensions over the past 50 years. Obesity is a disease that can cause premature disability and death by increasing the risk of cardiometabolic diseases, osteoarthritis, dementia, depression and some types of cancers. Obesity prevention and treatments frequently fail in the long term (for example, behavioural interventions aiming at reducing energy intake and increasing energy expenditure) or are not available or suitable (bariatric surgery) for the majority of people affected. Although obesity prevalence increased in every single country in the world, regional differences exist in both obesity prevalence and trends; understanding the drivers of these regional differences might help to provide guidance for the most promising intervention strategies. Changes in the global food system together with increased sedentary behaviour seem to be the main drivers of the obesity pandemic. The major challenge is to translate our knowledge of the main causes of increased obesity prevalence into effective actions; such actions might include policy changes that facilitate individual choices for foods that have reduced fat, sugar and salt content.  Paleolithic nutrition Boyd Eaton S et al, Am J Clin Nutr 2010 (paleolithic era: 2.5 millions years ago until the introduction of farming ~12,000 years ago)  Pima Indians Hunter gatherer Western lifestyle Pima Indians that live in Mexico: 10% have diabetes and the population in general is not overweight Pima Indians that live in the USA: 50% are overweight and 95% of the overweight people have diabetes  Adipose tissue cellularity Increase in adiposity (body fatness) is due to Fat cell hyperplasia (increase in number) Fat cell hyperthrophy (increase in size) Fat cell number and size increase in childhood obesity Fat cell number and weight gain in adults Fat cell number normally increases after birth, In adults, cells normally expand or shrink in size, during first years of life and during adolescent without changes in number ‘growth spurt’ Mildly obese: increase in size of existing fat cells Number increases more rapidly than usual in obese (hyperthrophy) = hyperthrophic obesity children during late childhood and early puberty Moderately obese: increase in size of existing cells Obesity in childhood is due to both an increase in and appearance of new cells: increase in size and number and size of adipocytes number= hyperthrophic and hyperplastic obesity Severely obese: significantly increased number of fat cells= hyperplastic obesity  Infancy and Mild adult obesity: Moderate to severe Fat loss decreases adolescence increase in size of obesity: further cell size but not normal increase in existing cells increase in number number cell number Hyperthrophic Hyperthrophic/ Leaving potential obesity hyperplastic for greater fat obesity deposition in the future  Fat cell number and risk of obesity Number of fat cells is the biggest factor in determining the risk of obesity Obesity in adolescence will affect obesity in adulthood Goal is to prevent fat cell number to increase during adolescent growing years, when adult number is determined People with extra fat cells may tend to regain rapidly any weight lost by dieting rapidly Nutritional and exercise interventions reduce fat cell size and decrease relative risk of obesity Obesity causes disease though abnormal production of hormones and inflammation in fat tissue Leptin: hormone that controls appetite and satiety (leptin resistance in obesity) Adiponectin: hormone that helps to regulate glucose and fatty acids metabolism and insulin sensitivity  Factors implicated in obesity Genetics Environment Psychology-Appetite Obesity is an heritable trait Impact on energy intake Inborn appetite Food readily available Child from normal parents has 14% Large portions Pleasure chance of becoming obese; one Energy dense obese parent, 30%; two obese Cheap Preferences and aversions parents, 70-80% Easily accessible Social influences Genetic contribution to expression of Impact on energy expenditure some obesity-related traits ≥ 50% Increased use of transport Pharmacological influences Movement of jobs from physical Genes may influence appetite, labour to sedentary Metabolic influences number of fat cells, fat mass and Sedentary environment distribution, resting metabolic state Environmental influences Easy to eat more and move less! Psychological stimuli (stress, boredom, depression, loneliness) may all trigger inappropriate eating Obesity treatment pyramid  Metabolic syndrome (MetS) MetS is a cluster of disorders linked with insulin resistance. It is defined by WHO as a pathologic condition characterized by abdominal obesity, insulin resistance, hypertension, and hyperlipidemia. MetS definition Abdominal fat is a major determinant of the MetS  Insulin resistance- what is it? Insulin resistance is a central component of MetS Insulin secretion rates are much higher in fasting state and after a meal but the response is impaired Insulin resistance can be present long before onset of hypeglycemia and diabetes – Pre-diabetic state It becomes MetS when associated to other components of the cluster  The most frequent MetS component present in obese individuals was elevated blood pressure. In the 10 studies, obesity coincided with hypertension in 60% to 85% cases. There were considerable variations in the prevalence of other components of MetS, especially blood glucose and HDL cholesterol.  Analysis revealed a consistently higher prevalence of the MHO phenotype in women compared to men The percentage of obese subjects with a favourable risk profile decreases with increasing age in all cohorts The Finnish cohorts had the highest prevalence of MetS among obese subjects and the lowest percentage of MHO The Italian MICROS and the Dutch LifeLines cohorts exhibit observed a lower prevalence of MetS among obese subjects together with a higher percentage of MHO  Why is the diagnosis of MetS important? MetS increases mortality MetS is a risk factor for mortality among normal-weight and obese adults. In this study, normal-weight adults with MetS had the highest mortality among the 6 groups studied, suggesting that interventions should also focus on MetS patients with normal weight.  Why is the diagnosis of MetS important? Can intervene with lifestyle modifications Diets work in decreasing body weight and ameliorate symptoms of MetS Liraglutide is an glucagon-like peptide agonist that reduces meal-related hyperglycemia and obesity Exercise, alone or in combination with drugs, improves MetS symptoms Why is the diagnosis of MetS important? Economic implications  Diabetes Diabetes is characterized by persistent hyperglycemia which results from defects in insulin secretion, or action or both Diabetes mellitus has been known since antiquity. Descriptions have been found in the Egyptian papyri, in ancient Indian and Chinese medical literature, as well as in the work of ancient Greek and Arab physicians In the 2nd century AD Aretaeus of Cappadocia provided the first accurate description of diabetes, coining the term diabetes In 17th century Thomas Willis added the term mellitus (sweet in latin) to the disease, in an attempt to describe the extremely sweet taste of the urine In 1921, Frederick Banting and Charles Best (Toronto, Canada) isolated insulin from pancreatic islets and administrated to patients suffering from type 1 diabetes, saving thus the lives of millions and inaugurating a new era in diabetes treatment  Insulin and its function α-cells = glucagon-producing, ~ 15–20% of the total islet cells β-cells = insulin-producing, ~ 65–80% of the total cells Maintenance of blood glucose levels by glucagon and insulin When blood glucose levels are low, the pancreas secretes glucagon, which increases endogenous blood glucose levels through glycogenolysis. After a meal, when exogenous blood glucose levels are high, insulin is released to trigger glucose uptake into insulin-dependent muscle and adipose tissues as well as to promote glycogenesis. Insulin and its function  Diabetes symptoms The following are symptoms of diabetes Urinate a lot, often at night Are very thirsty Lose weight without trying Are very hungry Blurry vision Numb or tingling hands or feet Tiredness Dry skin Sores that heal slowly Have more infections than usual There are two types of diabetes: type 1 diabetes (T1D) and type 2 diabetes (T2D) Type 1 diabetes (T1D) vs Type 2 diabetes (T2D) Symptoms of T1D People who have T1D may also have nausea, vomiting, or stomach pains. T1D symptoms can develop in just a few weeks or months and can be severe. T1D usually starts when you’re a child, teen, or young adult but can happen at any age. Symptoms of T2D T2D symptoms often take several years to develop. Some people don’t notice any symptoms at all. T2D usually starts when you’re an adult, though more and more children and teenagers are developing it. Because symptoms are hard to spot, it’s important to know the risk factors for T2D.  Risk factors for diabetes T1D T2D T1D is thought to be caused by an immune reaction fo the body Prediabetes against itself (by mistake). Risk factors for T1D are not as clear as T2D. Known risk factors include: Overweight Family history: Having a parent, brother, or sister with T1D Age: 45 years or older Age: T1D can occur at any age, but it usually develops in Having a parent, brother, or sister with T2D children, teens, or young adults Physical activity less than 3 times a week In the United States, White people are more likely to develop type 1 diabetes than African American and Hispanic or Latino Having had gestational diabetes (diabetes during people. pregnancy) or given birth to a baby who weighed over 4 kg Currently, no one knows how to prevent T1D. Being African American, Hispanic or Latino, American Indian, or Alaska Native person. Some Pacific Islanders and Asian American people are also at higher risk Non-alcoholic fatty liver disease may also increase risk  Gestational diabetes Gestational diabetes is a type of diabetes that can develop during pregnancy in women who don’t already have diabetes. Gestational diabetes occurs when the body cannot make enough insulin during the pregnancy. During pregnancy, the organism makes more hormones and goes through other changes, such as weight gain. These changes cause the cells of body to use insulin less effectively. Symptoms of Gestational Diabetes Diabetes during pregnancy usually does not have any symptoms. During pregnancy the doctor should test for gestational diabetes between 24 and 28 weeks of pregnancy.  Gestational diabetes: consequences Having gestational diabetes can increase the risk of high blood pressure during pregnancy. It can also increase the risk of having a large baby that needs to be delivered by cesarean section (C-section). In addition, if women have gestational diabetes, the baby is at higher risk of: Being very large (4 kg or more), which can make delivery more difficult Being born early, which can cause breathing and other problems Having low blood sugar Developing T2D later in life Blood sugar levels will usually return to normal after the baby is born. However, about 50% of women with gestational diabetes go on to develop T2D. Findings T1D and T2D increased over the the time period examined Children from racial and ethnic minority groups (non-Hispanic Black, Hispanic, American Indian) had a greater incidence of TD2 Pick age at diagnosis was 10 years for T1D and 16 years for T2D Trends in France by age Trends in France by region  Complications of diabetes Non vascular Vascular Infections Catarract Macrovascular Microvascular Myocardial infarction Retinopathy (eye damage) Peripheral vascular disease Nephropathy (renal failure) Cerebrovascular accidents Neuropathy (stroke) All due to small vessel damage Screening and monitoring diabetes History Physical examination Investigations on 1) blood glucose 2) glycated hemoglobin 3) urea and electrolytes (kidney) 4) urine protein – albumin 5) electrocardiogram 6) retinal photography  Treatment T1D T2D Insulin Diet (1st line of management) Diet Body weight control – fat down, muscle up Weight control Oral hypoglicemia drugs Insulin in later stages Objectives Objectives Maintain normal metabolic state (normoglycemia) Reduce insulin resistance Achieve normal growth Control blood glucose Reduce risk factors for Reduce risk factors for complications complications  Nutritional advice for people with diabetes People with T2D who are overweight or obese (BMI 25.0 and greater) should have a major focus placed on weight loss and increased physical activity. Obesity does not occur overnight, and its treatment requires lifetime adjustments to food (energy) intake and energy expenditure (increased activity). NO magic bullet for weight loss! Reduction of total calories consumed consistently leads to the loss and maintenance of body weight. Major goals: to promote and support healthful eating patterns, emphasizing a variety of nutrient dense foods in appropriate portion sizes in order to improve overall health and: Achieve and maintain body weight goals Attain individualized glycemic, blood pressure, and lipid goals Delay or prevent complications of diabetes Focus on low GI foods (see TD about Glycemic index) Total carbohydrates 45-50% energy, restriction of carbohydrates can be useful (but no less than 30%)  Carbohydrate intake should emphasize nutrient-dense carbohydrate sources that are high in fiber, including vegetables, fruits, legumes, whole grains, as well as dairy products. For people with T1D and T2D following flexible insulin therapy program, education on how to use carbohydrate counting, and also how to consider fat and protein content to determine mealtime insulin dosing is recommended to improve glycemic control. For individuals whose daily insulin dosing is fixed, a consistent pattern of carbohydrate intake with respect to time and amount may be recommended to improve glycemic control and reduce the risk of hypoglycemia. People with diabetes and those at risk are advised to avoid sugar-sweetened beverages (including fruit juices) and minimize the consumption of foods with added sugar that have the capacity to displace healthier, more nutrient- dense food choices  Nutritional advice for people with diabetes in France? From European Commission site: https://www.sfdiabete.org/sites/www.sfdiabete.org/files/files/ ressources/referentiel_mars2014.pdf