Alessandro Alessandro PintoPinto

Alimenti “buoni” e “cattivi”

nella patogenesi e nel

trattamento dell’obesitàLE FRONTIERE DEI DISTURBI DELL'ALIMENTAZIONE

CONGRESSO NAZIONALE SISDCA 2016

Roma, 26-27 Febbraio 2016

Aula magna, 1^ Clinica Medica

Policlinico Umberto I di Roma

Alessandro.pinto@uniroma1.it

Dipartimento di Medicina Sperimentale

Sezione di Fisiopatologia Medica, Scienza

dell’Alimentazione ed Endocrinologia

«alimento»

Reg CE 178/02 “qualsiasi sostanza o prodotto trasformato, parzialmente

trasformato o non trasformato, destinato ad essere ingerito, o di cui si

prevede ragionevolmente che possa essere ingerito, da esseri umani”

«Non sono compresi:

a) i mangimi;

b) gli animali vivi, a meno che siano preparati per l’immissione sul mercato ai fini del consumo umano;

c) i vegetali prima della raccolta;

d) i medicinali ai sensi delle direttive del Consiglio 65/65/CEE (1) e 92/73/CEE (2);

18-65 anni

Alimenti “cattivi” !!!

d) i medicinali ai sensi delle direttive del Consiglio 65/65/CEE (1) e 92/73/CEE (2);

e) i cosmetici ai sensi della direttiva 76/768/CEE del Consiglio (3);

f) il tabacco e i prodotti del tabacco ai sensi della direttiva 89/622/CEE del Consiglio (4);

g) le sostanze stupefacenti o psicotrope ai sensi della convenzione unica delle Nazioni Unite sugli stupefacenti del

1961 e della convenzione delle Nazioni Unite sulle sostanze psicotrope del 1971;

h) residui e contaminanti.”

“Sostanza che, introdotta nell’organismo, è in grado di fornire

energia e nutrienti indispensabili al normale svolgimento di funzioni

fondamentali per l’accrescimento e la vita dell’individuo”. aliménto s. m.

[dal lat. alimentum, der.di alĕre «nutrire»].

A.Bach-Faig et al - Public Health Nutrition: 2011, 14(12A), 2274–2284

Alimenti “buoni”!!!

Come ritiene sia la sua conoscenza

del rapporto alimentazione e salute?%

scarsa 16,0

sufficiente 46,1

83% ha dichiarato di aver ricevuto

informazioni sul tema

97% ritiene di avere uno stile alimentare

mediterraneo

Osservatorio sui consumi alimentari in Italia

Le conoscenze degli adulti !!!

sufficiente 46,1

buona 30,3

ottima 4,3

Non sa/Non Indicato 3,3

Totale 100,0

16% ha seguito una dieta nell’anno precedente

all’intervista

Progetto “Qualità Alimentare”

Indagine Eurisko 2013: più di 7 italiani su 10 dichiarano di mangiare in modo sano, ma solo il 15%

riesce a consumare la giusta quantità giornaliera di frutta e verdura.

% E da cereali, legumi, patate, ortaggi, frutta

fresca/secca, pesce, vino, olio d’oliva

% E da latte, formaggio, carne, uova, grassi

animali, margarina, bevande dolci, torte/biscotti

MAI =

1.Ancora troppa carne.

2.Legumi questi sconosciuti.3.Frutta e verdura: promosse dagli anziani e bocciate dai giovani

4.Ancora mediterranei nonostante tutto. Si conferma in larga parte l’aderenza al modello

alimentare mediterraneo con i cereali come alimenti base, l’olio di oliva come condimento e il vino comealimentare mediterraneo con i cereali come alimenti base, l’olio di oliva come condimento e il vino come

bevanda alcolica

Assunzione di MACRO nutrienti in Italia

Contributo percentuale di macronutrienti rispetto l’assunzione totale di energia in tutto il campione

in studio (0-99 anni), maschi e femmine Survey INRAN-SCAI 2005-06

Il contributo in energia da

macronutrienti conferma che

in Italia, come in altri Paesi

Proteine;

15,7%Lipidi; Alcol; 2,5%

% di energia da macronutrienti

in Italia, come in altri Paesi

industrializzati, l’apporto di

grassi è troppo elevato

mentre quello di carboidrati è

troppo ridotto.

Carboidrati;

45,5%

Lipidi;

36,2%

Acidi grassi saturi 11,2%

Acidi grassi monoinsaturi 17,5%

Acidi grassi polinsaturi 4,5%

Acidi grassi saturi 11,2%

Acidi grassi monoinsaturi 17,5%

Acidi grassi polinsaturi 4,5%

Nutrition, Metabolism & Cardiovascular Diseases (2011) 21, 922e932

di cui zuccheri semplici 15,0%

Nutrition transition and global dietary trend

increased availability

of fast food

unhealthy diets with a high calorie content; large portion sizes; and

large amounts of processed meat, highly refined carbohydrates,

sugary beverages, and unhealthy fats.sugary beverages, and unhealthy fats.

large chain

supermarkets

displace fresh local food and farm shops and serve as a source of

highly processed foods, high-energy snacks, and sugary beverages

in many developed and developing countries

livestock revolutionwhich leads to a rise in the production and consumption of beef,

pork, dairy products, eggs, and poultry

increased refinement

of grain products

milling and processing of whole grains to produce refined grains

such as polished white rice and refined wheat flour reduce the

nutritional content of grains, including their fibre, micronutrients,

and phytochemicals.

The healthy and Western dietary patterns differed

predominantly in fat and sugar intakes and explained 84 % of

the total variance in food intakes

The healthy pattern

• positively correlated with

whole grains, fruit,

vegetables, legumes, fish,

fiber, folic acid, and most

The Western pattern

• high intakes of take-away

foods, red meats, processed

meats, full-fat dairy

products, fried potatoes

Alimenti “cattivi” !!!Alimenti “buoni”!!!

fiber, folic acid, and most

micronutrients,

• inversely correlated with

energy from total fat,

saturated fat, and refined

sugar.

products, fried potatoes

( “ hot chips ” or “ French

fries ” ), refined cereals,

cakes and biscuits,

confectionery, soft drinks,

crisps, sauces, and

dressings.

Wendy H. Oddy, Am J Gastroenterol 2013; 108:778–785

L’obesità in età adulta: indagine Multiscopo dell’Istat “Aspetti Della Vita

Quotidiana. Anno 2009” in Italia nel periodo 2001-2009, è aumentata sia la % di

sovrappeso (dal 33,9% nel 2001 al 36,1% nel 2009) sia di obesità (dall’8,5% nel

2001 al 10,3% nel 2009).

La quota di popolazione in eccesso ponderale passa dal 19% tra i 18-24 anni a

>60% tra 55-74 anni, per poi diminuire lievemente nelle età più anziane (55,9%

>75 anni). Il 45,2% degli uomini è in sovrappeso e l’11,3% è obeso rispetto al

27,7% e al 9,3% delle donne.

Nel 2010 secondo i dati del Sistema Di Sorveglianza PASSI, negli adulti

www.epicentro.iss.it/problemi/obesita/epid.asp

Nel 2010 secondo i dati del Sistema Di Sorveglianza PASSI, negli adulti

sovrappeso 32%, obesità 11% : > 4 adulti su 10 (42%) sono in eccesso ponderale.

Dal confronto con le stime dei tre anni precedenti, nel quadriennio 2007-2010

la prevalenza dell’eccesso ponderale è stabile: 43% nel 2007 e nel 2008, 42% nel

2009 e nel 2010.

Obesity is already responsible for 2–8% of health costs and 10–13% of deaths in

different parts of the Region.

www.euro.who.int/en/what-we-do/health-topics/noncommunicable-diseases/obesity

Distal and proximal causes of obesity

BE. Sansbury and BG. Hill. Free Radic Biol Med. 2014

HypothesizedHypothesized relationshiprelationship betweenbetween

the environment and weight statusthe environment and weight status

obesity reviews (2011) 12, e95–e106

In terms of dietary factors, population trends in overweight and obesity would

suggest that energy intake exceeds energy expenditure.

obesity reviews (2011) 12, e95–e106

Population-based studies have shown that energy-dense diets are characterized by:

lower intakes of foods and nutrients

As there are physiological limitations on the quantity of food/drink that can be

consumed by individuals, excess energy intakes are often the consequence of energy-

dense diets (i.e. high in kilojoules per unit weight).

Population-level dietary estimates show that fat intakes exceed recommendations by at

least 10%, the majority of the population do not consume sufficient fruit, vegetables or

fibre and a significant proportion of the population skip meals.

• higher fat intakes

• greater intakes of energy-dense foods,including takeaway foods

• higher intakes of foods providing‘empty calories’ (e.g. sugar-sweetened drinks)

• lower intakes of foods and nutrientsthat may have appetite-controllingproperties (i.e. fruit and vegetables,fibre)

• meal patterns that interfere with theregulation of energy intakes (e.g.skipping breakfast)

Objectives

To assess the effects of proportion of energy intake from

fat on measures of weight and body fatness (including

obesity, waist circumference and body mass index) in

people not aiming to lose weight, using all appropriate

randomised controlled trials (RCTs) and cohort studies in

adults, children and young people.

Authors’ conclusions

Trials where participants were randomised to a lower

fat intake versus usual or moderate fat intake, but

with no intention to reduce weight, showed a

consistent, stable but small effect of low fat intake on

body fatness: slightly lower weight, BMI and waist

circumference compared with controls.

Greater fat reduction and lower baseline fat intakeGreater fat reduction and lower baseline fat intake

were both associated with greater reductions in

weight.

This effect of reducing total fat was not consistently

reflected in cohort studies assessing the relationship

between total fat intake and later measures of body

fatness or change in body fatness in studies of

children, young people or adults.

obesity reviews (2011) 12, e95–e106

1. Accessibility and availability. Increasing access to stores that promote

unhealthy food choices: takeaway and fast food shops, convenience stores and

other outlets that are less likely to sell healthy food choices.

2. Social conditions. These arise from inter-personal interactions (e.g.

marketing) and social support; living in a socioeconomically-deprived area was

‘Obesogenic’ food

environments

marketing) and social support; living in a socioeconomically-deprived area was

the only environmental factor consistently associated with a number of

obesogenic dietary behaviours.

3. Material conditions. Including unfavourable working, housing and

neighbourhood conditions (e.g. neighbourhood deprivation).

The environment may play an important role in the development of

overweight/obesity, however the dietary mechanisms that contribute to this remain

unclear and the physical activity environment may also play an important role in weight

gain, overweight and obesity.

Although many methodological differences among the studies performed to date

currently limit the ability to make comparisons, the results suggest there is a positive

relationship between the consumption of food away from home and weight gain.

‘Obesogenic’ food

environments

Many factors influence our dietary choices, including the expert marketers who advise

manufacturers on ways to encourage the population to buy more, especially

profitable, palatable ‘ultra-processed’ foods.

Supermarket ‘Bullying’

Findings from this review suggest that while a causal relationship cannot be stated, an

unequivocal association exists between increased fast food consumption and increased

caloric intake making individuals much more susceptible to weight gain and obesity.

Furthermore, in a recent publication by the World Cancer Research Fund and American

obesity reviews (2008) 9, 535–547

Furthermore, in a recent publication by the World Cancer Research Fund and American

Institute for Cancer Research, the expert panel found the current literature regarding fast

food consumption as a cause of weight gain, overweight and obesity strong and

consistent, resulting in recommendations for minimal fast food consumption.

While a plausible biological mechanism is present, many findings are subject to

interpretation bias as many methodological issues such as small sample size, short

duration of follow-up, inconsistency and repeatability of measurement of exposure

variables, in addition to inherent confounding by other lifestyle modifications, are

present among the published manuscripts.

• large portion size,

• high glycemic load,

• excessive amounts of refined starch and added sugars,

• the most cogent and comprehensive hypothesis is the energy density of fast food

Many plausible biological

mechanisms:obesity reviews (2008) 9, 535–547

• Humans possess a weak innate ability to recognize foods that are energy dense and

down-regulate the bulk of food eaten accordingly, […] such compensation was

insufficient as total caloric intake still increased substantially.

• The ability of energy dense food to interfere with appetite regulation may be

exacerbated in obese individuals and children.

• Obese individuals were unable to sufficiently adjust their caloric intake after a fast food

meal in comparison with lean individuals.

• Children are also suspected to be especially vulnerable to high energy density meals

because they have not yet developed the necessary cognitive dietary restraint .

• Traditional societies consumed largely unprocessed plant based diets that were

high in fiber and included whole grains, legumes and nuts as staples. These diets

There was consensus that diets low

in GI and GL were relevant to the

prevention and management of

diabetes and coronary heart

disease, and probably obesity.

high in fiber and included whole grains, legumes and nuts as staples. These diets

were low GI and low GL.

• The shift away from traditional diets to western highly processed diets has

paralleled a dramatic rise in the prevalence of diabetes, obesity and CVD.

• Epidemiological studies indicate that the consumption of plant-based diets reduce

risk of T2DM and CHD.

• The “fiber hypothesis” suggested that this was a direct effect of fiber. The GI

concept is an extension of the fiber hypothesis suggesting that fiber would reduce

the rate of nutrient influx from the gut.

• It has particular relevance to those chronic Western diseases associated with

central obesity and insulin resistance .

Methods: We followed-up 9 267 Spanish university graduates for a mean period of 5 years. Dietary

habits at baseline were assessed using a semi-quantitative 136-item food-frequency questionnaire.

Average yearly weight change was evaluated according to quintiles of baseline glycemic index,

glycemic load, and categories of bread consumption. We also assessed the association between

bread consumption, glycemic index, or glycemic load, and the incidence of overweight/obesity.

Background: To evaluate prospectively the

relationship between white, or whole grain

bread, and glycemic index, or glycemic load

from diet and weight change in a

Mediterranean cohort.

bread consumption, glycemic index, or glycemic load, and the incidence of overweight/obesity.

Conclusions

Despite evidence that low-GI and/or low-GL diets are independently associated with a

reduced risk of certain chronic diseases, our results suggest that dietary GI and dietary

GL were not associated with increased weight gain or an increased risk of

overweight/obesity development in a Mediterranean cohort of young adults with a low

average BMI and with a high intake of fruits and vegetables. In contrast, a high

consumption of white bread was a risk factor for overweight/obesity in the same

population. However, further studies, in special intervention studies, are needed before

including these measures in the dietary recommendations for healthy populations.

Aim: The aim of the present meta-

analysis was to investigate the long-term

effects of glycemic index-related diets in

the management of obesity with a

special emphasis on the potential

benefits of low glycemic index/load

(GI/GL) in the prevention of obesity-

associated risks.

Outcome of interest markers included anthropometric data as well as biomarkers of CVD and

glycemic control. 14 studies were included in the primary meta-analysis. Weighted mean

differences in change of C-reactive protein [WMD: 0.43 mg/dl, (95% CI 0.78 to 0.09), p Z 0.01], and

fasting insulin [WMD: 5.16 pmol/L, (95% CI 8.45 to 1.88), p Z 0.002] were significantly more fasting insulin [WMD: 5.16 pmol/L, (95% CI 8.45 to 1.88), p Z 0.002] were significantly more

pronounced in benefit of low GI/GL diets.

However decrease in fat free mass [WMD: 1.04 kg (95% CI 1.73 to 0.35), pZ0.003] was significantly

more pronounced following low GI/GL diets as well.

No significant changes were observed for blood lipids, anthropometric measures, HbA1c and fasting

glucose.

Decreases in C-reactive protein and fasting insulin remained statistically significant in the low GI/GL

subgroups.

Conclusions: The present systematic review provides evidence for beneficial effects of

longterm interventions administering a low glycemic index/load diet with respect to

fasting insulin

Ecological observations which have linked increasing fructose intake with increasing

obesity and diabetes rates along with animal models and select human trials of

fructose overfeeding at levels of exposure far beyond actual population levels of

intake have driven this debate.

Fructose the low-GI sugar: is there

cause for concern?

intake have driven this debate.

Although large prospective cohorts studies have shown significant positive

associations with incident obesity, diabetes, gout, CHD, and stroke when comparing

the highest with the lowest levels of intake of sugar sweetened beverages, these

associations do not hold true at moderate levels of intake or when modeling total

fructose (with the exception of gout). Similarly, the evidence from controlled

feeding trials shows that there is a reasonable body of consistent evidence from

controlled feeding trials that fructose in isocaloric exchange for other sources of

carbohydrate at low-to-moderate doses near the average U.S. intake of fructose

(10% total energy) does not have adverse effects.

Ann Intern Med. 2012;156:291-304.

Study Selection: At least 3 reviewers identified controlled feeding trials lasting 7 or more days that

compared the effect on body weight of free fructose and nonfructose carbohydrate in diets

providing similar calories (isocaloric trials) or of diets supplemented with free fructose to provide

excess energy and usual or control diets (hypercaloric trials). Trials evaluating high-fructose corn

syrup (42% to 55% free fructose) were excluded.

Data Synthesis: Thirty-one isocaloric trials (637 participants) and 10 hypercaloric trials (119Data Synthesis: Thirty-one isocaloric trials (637 participants) and 10 hypercaloric trials (119

participants) were included; studies tended to be small (15 participants), short (12 weeks), and of

low quality. Fructose had no overall effect on body weight in isocaloric trials (mean difference, 0.14

kg [95% CI, 0.37 to 0.10 kg] for fructose compared with non fructose carbohydrate). High doses of

fructose in hypercaloric trials (104 to 250 g/d, 18% to 97% of total daily energy intake) lead to

significant increases in weight (mean difference, 0.53 kg [CI, 0.26 to 0.79 kg] with fructose).

Limitations: Most trials had methodological limitations and were of poor quality. The weight-

increasing effect of fructose in hypercaloric trials may have been attributable to excess energy

rather than fructose itself.

Conclusion: Fructose does not seem to cause weight gain when it is substituted for other

carbohydrates in diets providing similar calories. Free fructose at high doses that provided excess

calories modestly increased body weight, an effect that may be due to the extra calories rather

than the fructose.

obesity reviews (2013) 14, 606–619

Among numerous potential dietary determinants of obesity, sugar-sweetened

beverages (SSBs) have recently received a great deal of attention, because they are

the largest source of calories and added sugars in both children and adults in the the largest source of calories and added sugars in both children and adults in the

United States.

Consumption of SSBs has increased dramatically in the past several decades among

both children and adults.

Additionally, SSBs have been clearly identified as a suitable target for public health

interventions, not only because SSB consumption is strongly associated with obesity,

but also because they offer only ‘empty’ calories and provide almost no nutritional

value.

obesity reviews (2013) 14, 606–619

Conclusions

Consumption of SSBs has increased markedly across the globe in recent decades, tracking closely Consumption of SSBs has increased markedly across the globe in recent decades, tracking closely

with the growing burdens of obesity. These beverages are currently the largest source of added

sugar intake and the top source of daily energy in the U.S. diet. The cumulative evidence from

observational studies and experimental trials is sufficient to conclude that regular consumption of

SSBs causes excess weight gain and these beverages are unique dietary contributors to obesity and

T2D. Compelling evidence indicates that reducing SSBs will have significant impact on the

prevalence of obesity and its related diseases, especially T2D. Despite strong resistance from the

beverage industry, several public policies and regulatory strategies to reduce intake of SSBs are

already in place or being developed. The combination of public health campaigns and regulations

and laws is needed to change social norms and dietary behaviours. Although reducing SSB

consumption alone is unlikely to solve the obesity epidemic entirely, limiting intake of SSBs is one

simple change that could have a measurable impact on weight control and prevention of T2D and

other metabolic diseases.

Take home messages

1. Il peggior nemico della salute è la disinfomazione!!!

2. La transizione verso un modello alimentare di tipo occidentale (alimentazione

iperlipidica, associata ad un eccessivo consumo di zuccheri semplici, cereali raffinati, alimenti di

origine animale, bevande zuccherate; scarso apporto di fibra e basso consumo di frutta, ortaggi,

legumi e pesce) risulta associata ad un’amentata prevalenza di obesità.

3. Il rischio di obesità è associato all’interazione tra un ambiente che promuove la

sedentarietà e un “ambiente alimentare obesiogeno” (fast food, takeaway, pasti

frequenti fuori casa, alimenti ad alta densità energetica nella grande

distribuzione).

4. Una dieta iperlipidica è associata ad un modesto ma significativo incremento4. Una dieta iperlipidica è associata ad un modesto ma significativo incremento

ponderale.

5. Il ruolo dell’indice glicemico non è stato chiarito, sebbene una dieta a basso

indice glicemico risulti associata ad un minore rischio di complicanze associate

all’obesità (riduzione PCR e insulinemia).

6. Il consumo di fruttosio è associato ad aumentato rischio di obesità e di steatosi a

dosaggi elevati, ma non a dosaggi adeguati.

7. Il largo consumo di bevande zuccherate costituisce un fattore di rischio

univocamente riconosciuto per l’obesità.

Alessandro Pinto