Nolan NHF for web.pdf - Nutrition and Health Foundation

Food and Fitness
Practical Solutions to Obesity
Nutrition & Health Foundation
John Nolan
St James’s Hospital
Trinity College Dublin

Obesity: Health Complications
• Type 2 diabetes
• Hypertension
• Cardiovascular diseases
• PCOS
• Cancer
• Fatty liver disease (NASH)
• Psychological illness
• Social - discrimination

Obesity: Common Assumptions
• It is simply a matter of behaviour
• It is just a balance sheet: calories in vs
calories out
• It is not a medical issue
Blame game

Blaming Food & the Food
Industry
• Problems arise from:
– Portion sizes
– How we shop
– How we cook
– Where and when we eat
Irish food is good!

Healthy diet and exercise

California cattle lifestyle

Exercise – diet – low stress - lean

Sedentary – stress - fat

‘Starter’ portion
Starter course:
20 x 10 cm
platter
~40 chicken
wings

32 ounce gulp

Bagel
20 Years Ago Today
Cheeseburger
20 Years Ago
Today
140 calories
350 calories 333 calories 590 calories
Chips
20 Years Ago Today
210 calories 610 calories

Nutrition Support
• Lack of access to good nutritional advice
• Fad diets
• Short-termism
• Denial
“Some people like food, however,
Other people like to eat”

Hypothalamic control of appetite
_
MCH
Orexins
Other
Hypothalamic
Nuclei
+ _
Lateral
Hypothalamus
+
POMC
ARCUATE
+ _
LEPTIN
NPY
AGRP
EAT!!!!

Blaming Inactivity
• We have a favourable climate
• Uncrowded countryside
BUT
• We lack access to good advice on physical
activity

Obesity: What we have learnt
• The problem is global
• Threat to population health in 21 st century
• The economic cost is huge
• Complex interplay between central drive to
eat and peripheral metabolism
• Genetic contributors
• Importance of early life

Early life effects on obesity
In utero milieu
Maternal factors
Obesity, GDM
Imprinting
Epigenetic events
Early infancy

50
40
Obesity Is A Risk Factor for
Type 2 Diabetes
Age-adjusted relative risk of type 2 diabetes
Men 1 42
100 Women 2
75
93
30
20
10
0
50
40
12
25
1.0
2.2
1.0
8.1

Early Onset Type 2 Diabetes Mellitus

SJH: Under 40’s compared to over 50’s with DM
Younger
T2DM n =
149
Older
T2DM n = 217
P
Value
Age (years) 35.2 (0.39) 61.6 (0.38)
Male % 67.00 63.59
Diastolic BP (mm/Hg) 80 (0.91) 78 (0.8) NS
C peptide at diagnosis
(µg/l)
Total Cholesterol
(mmol/l)
3.27 (0.34) 3.48 (0.25) NS
4.98 (0.12) 4.83 (0.07) NS
LDL (mmol/l) 2.83 (0.07) 2.79 (0.06 NS
Hatunic et al; Diabetes Vasc Dis Res 2005;2:73-75

Clinical and laboratory characteristics
BMI (kg/m2)
Younger
T2DM n =149
33.3 (1.65)
Older
T2DM n = 217
30.7 (0.5)
P Value

Young Type 2 DM (

Exercise & Mitochondrial
Function

Pre- and Post-Exercise Mean
VO 2 max
error bars represent SEM
VO2 max (ml/min/kg) .
4
3.5
3
2.5
2
1.5
1
0.5
***
Control
Young Type 2
***P

Fasting Free Fatty Acids
(FFA)
Error bars represent SEM
FFA (mmol/l) .
1
0.8
0.6
0.4
0.2
***
Control
Young Type 2
***P

Obesity: exercise responses
• Some individuals are less responsive to
aerobic exercise
• This may be due to genetic factors
• More likely to be mainly due to
environmental effects on metabolizing
tissues

Insulin sensitivity
control
obese
diabetic
control
obese
diabetic
< 30
exercise
Age (years)
> 30
exercise
Figure 2. Exercise intervention in middle aged and older subjects has been shown to improve insulin sensitivity
(right panel). However, we have shown that early onset obesity/insulin resistance is unresponsive to aerobic
exercise (left panel). Our current research focuses on potential cellular and molecular causes for this discrepancy

Costs related to obesity: For
discussion
• If it is only a question of economic
costs: should we not choose how to
re-target the money already being
spent on obesity complications?
• Investment now in prevention and
treatment, for later (minimum of 5
years later) savings?

COSTS OF DIABETES
Irish Data
Well care
~€1,000/yr
Illness care
~€5,000/yr

The average excess costs of treating DM
patients with and without complications
(per person and year and by the type of diabetes)
10000
8000
6000
4000
2000
0
516.6
9998.2
x 19
Euros / person a year
981.2
7947.4
x 8
Excess costs of type 2 Excess costs of type 1
n = 7 882 3 532 1 545 779
Without complications With complications
The average health care costs per person a year in the City
of Helsinki: 1 254 euros/person © TK 2005

Finnish Study :
A blueprint for treating IR
• Weight reduction 5%
• Fat intake 30 min per day (walking, jogging,
swimming, aerobic ball games, skiing)

Development of diabetes during the lifestyle intervention
in the intervention and control groups - DPS
1.0
0.9
0.8
0.7
0.6
0.5
Intervention
group
Control group
Risk reduction:
58%
0 1 2 3 4 5 6
Year

DPS – How was it done?
• 7 dietary counselling sessions during the
first year and every 3 months thereafter
• Individually tailored diet based on 3-day
food diaries
• Individually designed exercise programme

High risk
approach
Population
approach
Risk factor distribution
Identify and treat those
beyond a threshold for
risk factor
• Resource intensive
• Screening necessary
• Provable in RCT
• Large effect in small number of
people
Risk factor distribution
Shift the whole population
distribution of risk factor
lower
• Less resource intensive
• Less amenable to RCT
• No specific need to identify high risk
subjects
• Small effect in large number of people

THANK YOU FOR YOUR
ATTENTION