Ms. Bavinder Heer MRPharmS, Dip CNM

Integrative Health Practitioner

(Pharmacist & Nutritional Therapist)

Overview: Obesity

Energy – what can go wrong

Inflammation- what does it mean

Other factors

Current trends- do diets work?

Looking to the future...

Obesity Implicated as a risk factor for many different

disorders including:

CVD

Diabetes type II

Some Cancers

BPH

Female infertility & uterine fibroids

Gallstones

Pregnancy disorders such as pre-eclampsia

Relieving the economic burden of disease

“coronary heart disease, prostate and breast

cancer, diabetes and obesity account for 75% of

health-care costs, yet the progression of these

diseases can be stopped or even reversed with

intensive lifestyle changes.”

Ornish D. Lancet Oncol. 2009 Jul;10(7):638-9

Current trends:

Nutrition and Lifestyle

Intervention.

Functional Medicine:

Functional medicine involves understanding

the origins, prevention, and treatment of

complex, chronic disease.

Clinical psychoneuroimmunology and nutritional medicine (CPNI)

Interactions between the nervous system and the immune system, and the mutual relationship between behaviour and health.

The main disciplines that are brought together are psychology, neurology, immunology, endocrinology, evolutionary biology and epigenetics.

Research has revealed that human physiology and the external environment interact dynamically.

Considerations: Epigenetics: concerned with how our

environment changes gene expression

Proteomics: concerned with proteins

expressed by a genome.

Nutrigenomics: the science of how food

substances alter gene expression within

human cells.

Food is information for our epigenome (gene expression)

Food provides signals for cellular

function to programme for health and

disease.

What can go wrong?

An environmental mismatch:

“through nearly all human evolution genetic adaptation

was closely coupled with environmental alterations.

Now, however, cultural change comes too rapidly for

genetic accommodation to keep pace.”

Prev Med. 2002 Feb; 34(2): 109-18

Our environment is changing the way our genes are expressed

“ ...recent studies indicate that environmental factors &

diet can perturb the way genes are controlled by DNA

methylation & covalent histone modifications.

Unexpectedly, and not unlike genetic mutations, aberrant

epigenetic alterations and their phenotypic effects can

sometimes be passed on to the next generation.”

Mutat. Res. 2006 Aug 30;6001-2):46-57

Traditional model

Factors influencing glycaemic control Traditional model:

Regulation of blood sugar- insulin and glucagon

Functional model:

Metabolic Intelligence:

Balancing act, the adrenals, pituitary gland, intestines

and pancreas work in synchrony to achieve blood

glucose balance.

The effects of food

Losing equilibrium:

Corticosteroids

T3 & T4

Normal

catabolism

Growth

hormones

Sex hormones

Normal insulin

CATABOLISM ANABOLISM

How do we confuse the metabolic system?

Erratic eating patterns and fad diets may confuse the metabolic system

Poor blood sugar regulation will lead to reduced response to insulin

Breakdowns occur in signalling

Hypothalamus develops a resistance to leptin signals

(Halle & Persson, 2003) Primary role is to coordinate metabolic, endocrine and behvioural responses to starvation.

Reactive Hypoglycaemia.

Symptoms of Reactive Hypoglycaemia

Irritability

Anxiety

Depression

Mood swings

Poor concentration

Fat storage (midriff)

Brain fog

• Insomnia

• Cravings

• Excessive thirst

• Addictions

• Drowsiness

• Excessive sweating

How do we confuse the metabolic system?

Chronic stress and adrenal function-- stress elevated

cortisol induces insulin resistance and inflammation

Symptoms of high cortisol: intermittent fatigue,

irritability, dysglycaemia, sleep disturbances, central

obesity

The motion picture of Diabetes

Central cortisol resistance precedes peripheral

insulin resistance.

Garcia-Prieto et al.; Cortisol secretary pattern and glucocorticoid feedback

sensitivity in women from a Mediterranean area: relationship with anthropometric

characteristics, dietary intake and plasma fatty acid profile. Clin Endocrinol

(Oxf)). 2007 Feb;66(2):185-91.

Higher expression of glucocorticoid receptors on the

liver precede insulin resistance.

Clinical PNI – Metamodel 1

The symptom

Causes (nutrition, inactivity, lack of sunshine,

tabaco)

Insulin

resistance

Cortisol

Resistance

LGI

Proximate

medicine

The result:

Corticosteroids

T3 & T4

Normal

catabolism

Growth

hormones

Sex hormones

Abnormal

insulin

CATABOLISM ANABOLISM

Other factors: Thyroid function- sets metabolic rate and responsible

for energy release

Psychological factors- serotonin, dopamine

Immune Dysfunction- it is now widely accepted that

obesity is associated with a level of chronic

inflammation in the body.

Toxicity and its impact on mitochondrial function Chemical known as obesogens are known to induce obesity

Loss of circadian rhythm- studies have demonstrated that melatonin can reduce diet-induced obesity in rats (Prunet-Marcassus, 2003)

Imbalance of gut flora- function of ghrelin and leptin; Experiments performed on mice colonized with human gut microbes showed that changes in diet that resulted in the mice becoming obese (high carb to Western diet) allowed a rapid switch in microbial community.... when this modified gut flora was transferred to germ free mice, the obese phenotype was also passed on. (Turnbaugh P J et al, 2009)

The new shape:

Current trends: do DIEts work?

Insulin resistance is affected by the factors

mentioned earlier, what‟s also interesting is that

erratic eating patterns and fad diets may confuse the

metabolic system, a breakdown occurs in the

signalling, the hypothalamus develops a resistance

to leptin signals (Halle and Persson, 2003)

Evidence now clearly demonstrates that the body

gets “stingier” in its use of calories after each diet

(Muls E et al, 1995)

What is our aim:

Control dysglycaemia:

Minimise the effect of the

inflammation response

Improve anti-oxidant status

MEDITERRANEAN diet: Neopolitan researchers found that participants

assigned to a Mediterranean diet:

• Lost more weight

• Experienced greater improvements in glycaemic

control

• Showed improvements in coronary risk measures

(Esposito K, 2009)

Med-style diet for type 2 diabetes (Eposito et al 2009):

“compared with a low-fat diet, a low carbohydrate,

Mediterranean-style diet led to more favourable changes

in glycaemic control and coronary risk factors and

delayed the need for anti-hyperglycaemic drug therapy in

overweight patients with newly diagnosed type 2

diabetes.”

Ann Intern med. 2009 sep 1; 151(5): 306-14

REVIEW OF 35 STUDIES ON THE MED DIET

“The MED diet showed favourable effects on lipoprotein

levels, endothelium vasodilation, insulin resistance

metabolic syndrome, antioxidant capacity, myocardial

and cardiovascular mortality, and cancer incidence in

obese patients and those with previous myocardial

infarction.”

Serra-Majem et al.; Nutrition Reviews 64(2): S27-S47

MED diet reduces inflammation

“compared with patients consuming the control diet,

patients consuming the intervention diet had significantly

reduced serum concentrations of hs-CRP, IL-6, IL-7 & IL-

18, as well as decreased insulin resistance.”

Eposito et al., JAMA 2004;292:1440-1446

Mediterranean Diet:

• Rich in cereals, fruit, nuts, legumes, whole

grains, fish, olive oil

• Low in dairy, meat, junk food, fat

• High in beta-carotene, vitamin C, tocopherols,

polyphenols, minerals, soluble fibre.

What about fat??

“Consumption of mono-unsaturated fatty acids is

thought to increase insulin sensitivity, and this

component of the diet may explain the favourable

effect of the MED diet.”

Esposito K, 2009

Good fat is better than low fat: The Medl-RIVAGE study: reduction of CVR disease risk

factors after a 3-mo intervention with a MED-type diet or

a low fat diet.

“our data predicted a 9%reduction in cardiovascular

disease risk with the low-fat diet and 15% reduction with

this particular MED diet”

Vincent-Baudry et al.; Am J Clin Nutrition 2005; 82:964-71

Inflammation: immune dysfunction Morbid obesity is now known to be associated with low-

grade systemic inflammation & immune activation

Pro-inflammatory cytokines are synthesized and released in human adipose tissue :

TNF-alpha,

IL-1,

IL-6,

IFN-gamma

The anti-inflammatory diet “the MED diet ensures adequate intake of whole grains,

fruits, vegetables, nuts, fish, cereals, legumes and olive

oil; all this together with moderate consumption of

alcohol, predominantly wine, leads to high ingestion of

dietary fibre, antioxidants, magnesium and unsaturated

fatty acids. Therefore, the MED diet could serve as an

anti-inflammatory dietary pattern, which could protect

from or even treat diseases that are related to chronic

inflammation, including visceral obesity, type 2 diabetes

and the metabolic syndrome.” Giugliano D, Esposito K. MED diet & Metabolic diseases. Curr Opin Lipidol.

2008 Feb; 19(1):63-8

Benefits of the MED diet

Improved glycaemic control

Reduction in Cardiovascular risk

Reduction in inflammation

Micronutrients for genomic stability.... A new paradigm for RDAs

“current recommended dietary allowances for

vitamins & minerals are based largely on the

prevention of disease of deficiency, eg scurvy in the

case of vitamin C. Because diseases of

development, degenerative disease and aging itself

are partly caused by damage to DNA it seems logical

that we should focus better our attention on defining

optimal requirements of key minerals and vitamins

for preventing damage to both nuclear and

mitochondrial DNA.” Food and Chemical Toxicology 40(2002)1113-1117

Nutrients & compounds researched

Chromium

Magnesium

Alpha Lipoic Acid

Omega 3 EFAs

Manganese

Zinc

Vitamin D

Vitamin E

B vitamins

Vitamin C

Gymnema Sylvestre

Bitter Melon

Fenugreek

Bilberry

Gingko Biloba

Ginseng,

Garlic

Cinammon Results, are mixed and vary

according to the aims of the trial

Metabolic Foods Medical foods: “super-nutrition” containing nutrients

needed for specific clinical conditions.

Trial using these with MED diet, vs MED diet alone

Low GI (doesn‟t cause insulin spike)

Soy protein (for body composition & lipids)

2 g plant sterols(healthy cholesterol levels)

Targetted phytonutrients (cellular signal improvement)

Lifestyle Intervention: And not to forget activity levels:

To move or not to move?? That is the question.

• More frequent television viewing in adolescence and

early adulthood is associated with greater BMI gains

through to mid-adulthood and with central adiposity in

mid-life.

(Ashcroft, J 2008)

Activity „Our results strongly suggest that the increased risk of

obesity owing to genetic susceptibility can be blunted

through physical activity.

These findings suggest the important role of physical

activity in public health efforts to combat obesity,

particularly in genetically susceptible individuals.‟

Rampersaud E et al. Physical activity may help offset genetic risk for

obesity” Archives of Internal Medicine, 2008; 168:1791-1797

We are designed to move!

Nutrition is/as Medicine

Nutritional intervention is the upstream intervention

in people with metabolic disorders in Diabetes

.... In contrast medical intervention is approximate

downstream intervention for people suffering with

metabolic disorders.

The proximate intervention should be used to gain

time for repairing the motion picture.

Shokran