Dra Pilar Riobó MD, PhD Associate Head

Endocrinology and Nutrition Department

Hospital Fundacion Jimenez Diaz-Capio. Madrid

SAMEM 2013

Hidratación y balance energético

Requerimientos diarios de liquidos (Adultos 19-50 años)

Institute of Medicine (2004). Dietary Reference Intakes for water, potassium, sodium, chloride, and sulfate.www.iom.edu

El agua corporal total esta regulada muy estrechamente dentro del 0.2% del peso corporal:

. Perdida del 1% aumenta la osmolaridad

. Perdida del 2% afecta al rendimiento

Sed se estimula por:

. aumento de la osmolaridad plasmatica

. disminucion volumen plasmatico y TA

. Vasopresina, ADH

Decline in cognitive function resulting from dehydration

Lieberman HR 2007

Gopinathan , 1988

Se realizaron tests de funcion cognitiva para evaluar el efecto de diferentes grados de deshidratacion

Con un 2% deshidratacion inducida por ejercicio:   Alteracion de función motora   Alteracion de memoria a corto plazo  Disminucion de capacidad de atencion   Alteracion capacidad aritmetica

Funciones cognitivas y motoras alteradas por la deshidratacion

Cian, 2000

Grandjean AC et al. Dehydration and cognitive performance. J Am Coll Nutr.2007; 26:549S-554S

Symbol substitution test effects were observed at the 3% level of dehydration

(p < .05),

Eye-hand coordination effects were observed at all three levels of dehydration

Significant dose-related effects of dehydration

Sharma VM, Sridharan K, Pichan G, Panwar MR: Influence of heat-stress

induced dehydration on mental functions.Ergonomics29 :791,1986

“How well can you concentrate just now?”

“How sore does your head feel now?”

Changes in body mass over time for fluid restriction and euhydration conditions

Subjects reported feelings of headache during the trial and their ability to concentrate and their alertness were reduced.

Decrements in psychomotor, and cognitive performance can occur when> 2% of body weight is lost due to water restriction, heat,

and/or physical exertion

A major limitation of most studies conducted to date is the inability to determine the effects of

dehydration independent of the effects of thermal stress, physical stress, and/or fatigue.

Mild dehydration impairs cognitive performance and mood

  Randomised, single-blind, trial (N= 26)   exercise-induced dehydration plus a diuretic   exercise-induced dehydration plus placebo   exercise while maintaining euhydration , plus placebo

  A cognitive test battery, mood states and symptom questionnaire (headache, concentration and task difficulty) was administered

Dehydration degraded aspects of cognitive performance:   errors increased on visual vigilance   visual working memory response latency slowed   Fatigue and tension/anxiety increased   Plasma osmolality increased but resting temperature was not altered

Ganio, MS. Br J Nutr. 2011;106(10):1535-43

Even mild dehydration without hyperthermia induced adverse changes in vigilance and working memory, and

increased tension/anxiety and fatigue.

Deshidratacion y eventos isquemicos cerebrales. THIRST Study

 Ptes ingresados por ACVA vs. Control.  NHANES 1999-04

 Se calculo Osm p, tras ajustar diuréticos, diabetes...

 Osm p de pp era mas alta que la de los controles (295.4 vs. 292.3 mOsm/kg, P = 0.006), sugestivo de deplacion de volumen. Este parece ser un fenomeno precoz y , posiblemente, contribuyente, a la isquemia cerebral

BENEFICIOS DE ALTA INGESTA DE LIQUIDOS

Prevención de enfermedades (estudios cohortes)   Mejor función cognitiva   Menor incidencia neo vejiga:

 ↓7% por cada 240 mL de fluidos extra   Correlación con riesgo cancer colorrectal:

 Beneficios con tan sólo 5 vasos al día   Enfermedad coronaria fatal:

 ↓41% en Mujer y 54% en Varon si >5 vasos vs <2   Infecciones urinarias, litiasis renal:

 Susceptibilidad individual Valtin H. Am J Physiol Regul Integr Comp Physiol. 2002 ;283(5):R993-1004.

Michaud D et al. N Engl J Med 1999;340:1390-1397

Risk of Bladder Cancer Associated with Total Daily Fluid Intake

La variedad de sabores y bebidas contribuye a cubrir los requerimientos

diarios de líquidos

Son las bebidas edulcoradas las culpables de la obesidad??

Overweight and Obesity are Epidemic

LA TASA DE OBESIDAD PODRÍA DOBLARSE EN LOS PRÓXIMOS 25 AÑOS

IOTF collated data 2002

The Rising Rate of Childhood Obesity is Alarming

“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

Obesity Today: Future Impact

Framingham Heart Study

Obesity and overweight have been reported to be associated with decreases in life expectancy.

Peeters, A, et al. Ann Int Med 2003;138:24-32.

Non-smoking women Non-smoking men Smoking women Smoking men

7.08

13.3

5.82

13.7

0 5 10 15

Implications of obesity at age 40 on life expectancy.

Non-smoking women lost 7 years, Non-smoking men 5.8 years

Women Men

Willett WC, et al. N Engl J Med. 1999;341:427–434.

IMC (kg/m2) ‏

Rie

sgo

Rel

ativ

o

IMC (kg/m2) ‏

Relacion entre IMC y enfermedades cronicas en varones y mujeres

Hipertension Cholelitiasis DM2 Enfermedad coronaria

<21 22 23 24 25 26 27 28 29 30

4

6

5

3

2

1

0 <21 22 23 24 25 26 27 28 29 30

Diabetes epidemic

La obesidad se asocia con un incremento del riesgo para la mayoria de los canceres

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

Type

of C

ance

r (H

ighe

st B

MI c

ateg

ory) ‏

Relative Risk of Death (95% Confidence Interval) ‏

Multiple myeloma (>35) ‏Colon & Rectum (>40) ‏

Ovary (>35) ‏Liver (>35) ‏

All Cancers (>40) ‏Non-Hodgkin’s Lymphoma (>35) ‏

Gallbladder (>30) ‏All Other Cancers (>40) ‏

Oesophagus (>30) ‏Pancreas (>40) ‏

Kidney (>40) ‏

0 1 2 3 4 5 6 7 8 9 10 11

1.44 1.46 1.51

1.68 1.88 1.95

2.13 2.51* 2.64*

2.76

4.75

Breast (>40) ‏2.12

Cervix (>35) ‏3.20

Uterus (>40) ‏6.25

Women

Obesity and other risk factors

OBESITY

Blood pressure

HDL-C

Diabetes TG,Lp(a) sdLDL

Insulín Resistance

pro-thrombotic factors

PCRP

T-Cholesterol-t

IMC

Porc

enta

je

20 25 30 35 40

0

10

5

15

Diabetes y Obesidad

Brown WJ et al. Int J Obes 1998;22:520-528.

Relación entre IMC y porcentaje de mujeres que comunicaron problemas médicos, quirúrgicos, síntomas y utilización de los servicios sanitarios.

Hipertensión y Obesidad

IMC

Porc

enta

je

20 25 30 35 40

20

10

30

50

40

60

Relación entre IMC y porcentaje de mujeres que comunicaron problemas médicos, quirúrgicos, síntomas y utilización de los servicios sanitarios.

Brown WJ et al. Int J Obes 1998;22:520-528.

La causa biologca es sencilla

Un disbalance de alorias ingeridas y gastadas!

pero…

…Los factores sociales que contribuyen son complejos

•  El cambio de los habitos alimentarios • Comer solo, falta de comidas en familia • Porciones de mayor tamaño •  Incorporacion mujer al mundo laboral • Presion de industria alimentaria y publicidad

  Sedentarismo, disminución de ejercicio: 200cal/d

• El aumento del ocio sedentario

•  Cambio del ambiente fisico (urbano...)‏

•  Disponibilidad de alimentos (asequibilidad) con elevado contenido energético

•  Efectos secundarios de farmacos (psicofarmacos, alergia...)

•  Stress, factores psicológicos

•  Falta de sueño

•  Factores hormonales y genéticos : Leptina, Neuropéptido Y, UCP-2

Weight Issues

Patogenia de la obesidad: vida sedentaria

 Una diferencia de tan sólo un 2 % entre ingesta y gasto, todos los días del año supone una ganancia de unas 18000 Kcal (2 Kg de grasa) disminución de unas 200 Kcal / día,

 coches, ascensores, TV, ordenadores también favorecen el sedentarismo.

 Telefonos moviles:  20 llamadas/día x 20 m= 25 h andar/año  1h caminar=113-226 Kcal  Se ahorran: 2800-5000 Kcal/año = 0.7-0.8 Kg

grasa/año

Prevalencia obesidad en Valencia Tiempo diario dedicado a ver TV

Vioque J, et al. Int J Obes 2000; 24: 1683-1688

OR 2,38 > 4 h vs < 1 h /día

¿ES POSIBLE, EN LA PRÁCTICA, QUE SE PRODUZCAN CAMBIOS EN EL ESTILO DE VIDA?

Efectos intergeneracionales del ambiente intrauterino

Effectos en la descendencia

Efectos metabolicos durante el embarazo

 

Restrictive diets decrease metabolic rate

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

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.

Fructose intake correlates closely with the rate of diabetes worldwide

Fat makes us fat?? Direct relationship between fat intake and weight

•  obesity epidemic coincides con decreasing carbohydrate intake •  Higher caloric content/gram •  Difficult oxidation compared to carbs (Carbs are inmediatly oxidated) •  Higher palatability promotes increased consumption

 severe depression in 32% of obese patients  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.

Psychological problems

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

La falta de sueño y las alteraciones del sueño alteran las hormonas que reguan la ingesta. Leptina (saciedad)&

ghrelian hambre)

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

Antihistaminics Antidepresants and psychotropic Corticoids Beta-blockers Contraceptives Anti-ulcers

Weight gain as side effect of drugs

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

Wiklund P et al. Public Health Nutr. 2011;23:1-8

Prolonged breast-feeding protects mothers from later-life obesity

But rates of breast feeding are low

Frequency of Shared Family Meals

Pediatrics 2011;127:e1565

sharing 3 or more family meals per week reduces odds overweight (12%), eating disorders (35%)

Among married couples, when an alter became obese, the spouse was 37% more likely to become obese. If an ego had an obese friend, the ego’s chances of becoming obese increase by 57%. Between mutual friends, the ego’s risk of obesity increased by 171%

Friends Framingham Heart Study cohort

Having obese social contacts might lead to adopt specific behaviors

Could obesity be considered contagious???

The increased time spent in sedentary screen-based activities has also been implicated as

contributing to overweight and obesity .

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).

Television (TV) viewing: the dominant recreational pastime at all ages

Children who watched the most television during childhood had the greatest increase in body fat over time

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

70 children randomized to an intervention to reduce their television viewing and computer use by 50% vs control

Epstein. ARCH PEDIATR ADOLESC MED/ 2008

Reducing television viewing and computer use may have an important role in preventing obesity

In the intervention group, reductions in BMI and energy intake were shown

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 ??

Light at night increases body mass in mice

Fonken LK. Proc Natl Acad Sci. 2010; 26:18664-9.

Food Selection: What’s Important?

Source: FMI Trends, 2000

Taste has the additional value of contributing to the overall pleasure and enjoyment of a food

• Sweet taste permits the identification of energy-rich nutrients

• Umami (savoury/meaty taste) allows recognition of protein

• Salty taste ensures proper electrolyte balance

• Sour and Bitter tastes warn against the intake of potentially poisonous chemicals

 Consumption of sugar-sweetened beverages has been associated with weight gain in most observational studies, though not all such studies.

 However, children who drink more sugar-sweetened beverages also tend to eat more fast food and to watch more television.

  Thirty publications   positive association between greater intakes

of SSBs and weight gain and obesity in both children and adults

The weight of epidemiologic and experimental evidence indicates that a greater consumption of SSBs is associated with weight gain and obesity.

. Am J Clin Nutr 2006;84:274–88

LCS  Saccharin, discovered in 1878  Cyclamate in Europe (in 1969, banned in the US due to association with bladder cancer in rats. Subsequent review of the evidence raised questions about the trials, but remained unapproved in USA  Aspartame, approved for use in food 1981,  Acesulfame-K  Sucralose  Neotame  Stevia, a herb with intense sweetness

Artificial sweetener use and obesity trends in the United States

Use of Sweetners in USA (millions tons)

Calorie savings available by choosing foods and drinks with LCS

Calories (kcal)

Product With sugar Low calorie sweeteners

Carbonated soft drinks Powdered soft drinks Desserts Milk shake mix Fruit yoghurt Table top sweetener Table top sweetener

330 ml 240 ml 240 ml 180 ml 180 g tablets powder

145 86

150 110 207

16 16

2 5

75 50 81

1 2

Key questions   el cambio de un edulcorante calorico po

uno hipocalorico produce disminucion de peso?

  El sabor dulce (con o sin energia) produce un mayor consumo o de alguna forma se compensa?

Weight

7% decrease in calorie

intake when subjects drank

APM-sweetened

soda

1.  , 3. 

.

Am J Clin Nutr 90

normal-weight subjects 1 150 g /day soda sweetened with aspartame HFCS , for 3 wk

After 10 wk, the sucrose group had increases in total

energy, sucrose, and carbohydrate intakes and decreases in fat and protein intakes

Raben A et al. Am J Clin Nutr 2002 ;76:721

Energy and macronutrient intakes from ad libitum diet at 0, 5, 10 weeks

Significant reduction in energy intake with

aspartame mean reduction of

about 10% of energy intake.

Meta-analyses

de La Hunty Br Nutr Found Bull. 2006: 31; 115-128

16 studies Subjects in 3 trials were obese

Significant reduction in weight about a 3% reduction in body

weight

Meta-analyses: 16 studies

de La Hunty Br Nutr Found Nutr Bull. 2006

Masked replacement of sugar-containing beverages with noncaloric

beverages reduced weight gain and fat accumulation in

normal-weight children

Among overweight and obese adolescents, the increase in BMI was smaller in the experimental group than in the

control group after a 1-year intervention designed to reduce consumption of sugar-sweetened beverages, but

not at 2-y

GLP-1 secretion after diet soda ingestion in volunteers due to stimulation of gut taste receptors by LCS

synergizing with glucose-mediated stimulation of GLP-1 release.

74

Thank you very much for your attention