Panorama actual y epidemiología de la obesidad

Transcription

1 Panorama actual y epidemiología de la obesidad Dra. Mònica Bulló Unidad de Nutrición Humana: prevención y epigenética Universitat Rovira i Virgili (URV)-IISPV-CIBER

2 Outline 1. Background. Prevalence and incidence of overweight/obesity 2. Morbidity/Mortality 3. Screening 4. Interventions 5. Future research efforts

3 Background Prevalence/Incidence

4 OBESIDAD: La epidemia del siglo XXI 1.9 billones de adultos con sobrepeso (39%) 650 millones con obesidad (13%) 41 millones de niños < 5años con sobrepeso 340 millones de niños > 5años con sobrepeso

5 Prevalence of overweight among adults, aged 18+, Men Prevalence of obesity in 1975 (distribution by country) Women Prevalence of obesity in 2016 (distribution by country)

6 Prevalence of obesity among adults, aged 18+, Men Prevalence of obesity in 1975 (distribution by country) Women Prevalence of obesity in 2016 (distribution by country)

7 Prevalence of overweight among children and adolescents, Prevalence of obesity among children and adolescents,

8 Sobrepeso y obesidad: situación en España Gutiérrez-Fisac JL et al. Med Clin (Barc) 1994;102:10-3. Datos autorreportados extraídos de la Encuesta Nacional de Salud Obesidad ( 30) Sobrepeso Prevalencia global: 14,5% 39,5% Mujeres: 15,75% 32,0% Varones: 13,39% 45,0% Aranceta J et al. Prevalencia de la obesidad en España: estudio SEEDO 97. Med Clin (Barc) 1998;111: Mediciones antropométricas población años Aranceta J et al. Prevalencia de la obesidad en España: resultados de estudio SEEDO Med Clin (Barc) 2003; 120(16): Población años

9 Sobrepeso y obesidad: situación en España Estudio ENRICA Gutiérrez-Fisac JL, et al. Obes Rev 2012 Obesidad: 24,4% Sobrepeso: 46,4% Obesidad: 21,4% Sobrepeso: 32,5% personas en el periodo de junio de 2008 a octubre de ,4% sobrepeso 22,9% obesidad

10 Estudio ENPE Estudio transversal en muestra representativa de la población no institucionalizada de entre 25 y 64 años (n=3.801) entre Prevalencia de sobrepeso 39,3% Prevalencia de obesidad 21,6% Prevalencia obesidad abdominal: 33,4%

11 Sobrepeso y obesidad infantil: evolución en España Estudio enkid varones y mujeres de entre 2 y 24 años (423 niños entre 6-9 años) ( ) 14,5% sobrepeso 15,9% obesidad niños y niñas de 6-9 años distribuidos en centros escolares de todas las CC.AA entre ,2% sobrepeso 18,3% obesidad niños y niñas de 6-9 años distribuidos en centros escolares de todas las CC.AA entre ,2% sobrepeso 18,1% obesidad

12 Prevalence and sociodemographic correlates of overweight and obesity in a large Pan-European cohort of preschool children and their families: the ToyBox study Yannis Manios...(Luis A Moreno) et al. Nutrition, May preschool children ( years) and their parents participated in the ToyBox-study. Children's weight and height were measured, while parents self-reported their weight, height and family sociodemographic data in questionnaires Prevalence of overweight/obesity (IOTF criteria) among preschool children from the six countries participating in the ToyBox-study * p<0.001, for differences of % obesity levels across the six European countries (Greece>Poland, Belgium, Germany). ** p<0.001, for differences of %overweight/obesity levels across the six European countries (Greece>Bulgaria, Spain, Poland, Belgium, Germany; Bulgaria>Germany; Spain>Germany Prevalence of childhood overweight/obesity by parental weight status in the total sample and in the six countries participating in the ToyBox-study

13 Worldwide trends in insufficient physical activity from 2001 to 2016: a pooled analysis of 358 populationbased surveys with 1 9 million participants Regina Guthold, at al. Lancet Glob Health 2018 Data from 358 population-based surveys across 168 countries, reporting the prevalence of insufficient physical activity, which included physical activity at work, at home, for transport, and during leisure time (ie, not doing at least 150 min of moderate-intensity, or 75 min of vigorous-intensity physical activity per week, or any equivalent combination of the two) Country prevalence of insufficient physical activity in men and in women in 2016 Trends in insufficient physical activity for three income groups from 2001 to 2016

14 Morbidity/mortality Effects on population health

15 Medical complications of obesity Alzeheimer

16 Physical Health, Psychosocial, and functional consequences of Obesity over the Life Course

17 Cardiovascular disease, chronic kidney disease, and diabetes mortality burden of cardiometabolic risk factors from 1980 to 2010: a comparative risk assessment. Global Burden of Metabolic Risk Factors for Chronic Diseases Collaboration. Lancet Diabetes Endocrinol After accounting for multicausality, 63% of deaths from these diseases in 2010 were attributable to the combined effect of 4 metabolic risk factors, compared with 67% in The mortality burden of high BMI and glucose nearly doubled from 1980 to 2010

18 Data from 68.5 million persons among children and adults between 1980 and Global Disability-Adjusted Life-Years and Deaths Associated with a High BMI ( ). 1st. CVD 2nd. CKD Since 1980, the prevalence of obesity has doubled in more than 70 countries. The rate of increase in childhood obesity in many countries has been greater than the rate of increase in adult obesity. High BMI accounted for 4.0 million deaths globally (more than 2/3 were due to CVD). 1st. CVD 2nd. T2D Number of global disability-adjusted life-years related to a high BMI among adults according to the cause and the level of BMI in 1990 (Panel A) and in 2015 (Panel B) and the number of global deaths (in millions) related to high BMI in 1990 (Panel C) and in 2015 (Panel D). The two vertical lines mark the BMI thresholds for overweight (25-29) and for obesity ( 30). The percentages indicate the proportion of the total number of disability-adjusted life-years or deaths that were contributed by each of the listed disorders.

19 Cancer and obesity

20 Obesity and neurodegenerative disorders Obesity Insulin resistance Type 3 diabetes O Brien PD, et al. Lancet Neurol 2017; 16: Damage to the central nervous system Apoptosis or cell necrosis Alteration of the synaptic plasticity Neurodegenerative disorders Body mass index and risk of dementia: Analysis of individual-level data from 1.3 million individuals Kiwimaki M et al. Alzeheimers Dement 2018 Data from dementia-free participants from 39 cohort studies Hazard ratios per 5-kg/m 2 increase in BMI for dementia was 1.16 (95% confidence interval ) when BMI was assessed >20 years before dementia diagnosis.

21 The influence of obesity and weight gain on quality of life according to the SF-36 for individuals of the dynamic follow-up cohort of the University of Navarra Barcones-Moleroa, et. Revista Clínica Española ,033 participants of the dynamic cohort of the Follow-up Program of the Unversity of Navarra (SUN cohort). The quality of life was measured with the SF-36 questionnaire Physical function, general health and the physical component summary were inferior in individuals with excess weight and obesity

22 The Obesity Paradox...or reverse epidemiology Do we really need to lose weight? Obesity Paradox Does Exist Hainer V et al. Diabetes Care 2013

23 PLOS ONE 2015 Forest plot showing individual and pooled relative risks of allcause mortality with 95% confidence intervals across 12 randomized clinical trials of weight loss interventions 15 RCT, duration 18 months, 17,186 participants Intentional weight loss may be associated with approximately a 15% reduction in all-cause mortality.

24 Cardiovascular Effects of Intensive Lifestyle Intervention in Type 2 Diabetes The Look AHEAD Research Group N Engl J Med Jul 11; 369(2): ,145 OW/OB individuals with T2D randomized either to an intensive lifestyle intervention which promoted weight loss through decreased calorie intake and increased physical activity, or diabetes support and education. Planned follow-up of 13.5y (maximum achieved 9.6y) Cumulative Hazard Curves for the Primary Composite End Point. Intensive lifestyle intervention focused on weight loss did not reduce cardiovascular events in overweight or obese adults with type 2 diabetes.

25 Baja en grasa DietMed DietMed + Restricción calórica + Actividad física + Intervención conductual Pérdida peso mantenimiento a largo plazo CVD

26 CENTROS RECLUTADORES 23 Recruiting centres PREDIMED 1 centres New centres Hospital Txagorritxu, Vitoria Facultad de Medicina, Universidad de Navarra Facultad de Farmacia y Ciencias, Universidad de Navarra Universitat de León Hospital Ramón y Cajal, Madrid CSIC, Madrid Hospital Clínico de Madrid Universitat Jaume I, Castellón IDIBAPS, Hospital Clínic, Barcelona IMIM, Barcelona Hospital de Bellvitge, Barcelona Hospital Clínic, Barcelona Facultad de Medicina de Reus, Universitat Rovira i Virgili Universitat de les Illes Balears Hospital Son Dureta, Palma de Mallorca Facultad de Medicina, Universitat de València Universidad de Córdoba Universitat de Jaén Facultad de Medicina, Universidad Miguel Hernández, Sant Joan d'alacant (Alicante) Universidad de las Palmas de Gran Canaria Hospital Universitario Virgen de la Victoria de Málaga Instituto de la Grasa CSIC, Sevilla Facultad de Medicia, Universidad de Málaga In red you can see the recruiter centers of the PREDIMED I, and in green the new recruiters centers of PREDIMED PLUS project.

27 DISEÑO Y MÉTODOS Participantes elegibles n= 9677 Aleatorización n= 6874 Criterios de elegibilidad: a (60-75 M) IMC: kg/m 2 Cumplir 3 criterios del SM Sin ECV previa < 25% diabéticos n = 3406 n = 3468 Grupo de Intervención DietMed hipocalórica + Promoción de la AF + Soporte conductual Grupo control (DietMed)

28 PROTOCOLO DE INTERVENCIÓN Seguimiento Cribado Aleatorizacióm Individual + sesión grupal + contacto telefónico Inicio 1 M 2 M 3 M 4 M 5 M 6 M 7 M 8 M 9 M 10 M 12 M 1 er Año* GRUPO DE INTERVENCIÓN (DietMed hipocalórica + AF + soporte conductual) Rodaje 4 semanas GRUPO CONTROL (DietMed) Inicio 6 M Individual + sesión grupal 1 er Año y años sucesivos * De los 2-6 años para el Grupo de intervención: Después del primer año y en cada uno de los años restantes del ensayo, los participantes asistirán a: una sesión individual trimestral y una sesión de grupo mensual y dos llamadas telefónicas trimestral

29 Effect of a lifestyle intervention program with energy-restricted Mediterranean diet and exercise on weight loss and cardiovascular risk factors: One-year results of the PREDIMED-Plus trial Salas-Salvadó J et al, Diabetes Care 2018 Changes in weight loss at 6 and 12 months according to the intervention group Variable Change in body weight (kg) Intention-to-treat n=626 Intervention vs control Between-group differences P value Per protocol analysis n=584 P value At month (-2.4 to -1.4) < (-2.5 to -1.4) <0.001 At month (-3.2 to -1.9) < (-3.2 to -1.9) <0.001 Change in body weight (%) At month (-2.8, -1.6) < (-2.8, -1.6) <0.001 At month (-3.6, -2.3) < (-3.7, -2.3) <0.001 Change in BMI (kg/m 2 ) At month (-0.9 to -0.5) < (-0.9 to -0.5) <0.001 At month (-1.2 to -0.7) < (-1.2 to -0.7) <0.001 Changes in adiposity and CVD risk factors according to the intervention group Variable Waist circumference (cm) Intervention vs Control Between-group difference Intention-to-treat (MI) P value Completers-only P value 6-month change -2.1 (-2.9 to -1.3) < (-3.1 to -1.4) < month change -2.5 (-3.4 to -1.5) < (-3.5 to -1.6) <0.001 Glucose (mmol/l) 6-month change (-0.37 to -0.03) (-0.38 to -0.03) month change (-0.56 to -0.13) (-0.59 to -0.16) HbA1c (%)* 6-month change (-0.17 to -0.03) (-0.18 to -0.02) month change (-0.21 to -0.02) (-0.17 to -0.02) 0.01 Insulin (pmol/l) 12-month change (-30.7 to -6.9) (-31.5 to -8.7) HOMA-IR index 12-month change (-1.60 to -0.58) < (-1.52 to -0.52) <0.001 Total cholesterol (mmol/l) 6-month change 0.02 (-0.10 to 0.13) (-0.08 to 0.16) month change 0.02 (-0.11 to 0.15) (-0.08 to 0.17) 0.48 HDL cholesterol (mmol/l) 6-month change 0.03 (0.01 to 0.06) (0.01 to 0.06) month change 0.06 (0.03 to 0.09) < (0.03 to 0.09) <0.001 LDL cholesterol (mmol/l) 6-month change 0.02 (-0.09 to 0.12) (-0.07 to 0.14) month change 0.04 (-0.08 to 0.15) (-0.07 to 0.16) 0.42 Total cholesterol/hdl cholesterol ratio 6-month change (-0.18 to 0.04) (-0.17 to 0.05) month change (-0.28 to -0.03) (-0.26 to -0.02) 0.02 Triglycerides (mmol/l) 6-month change (-0.16 to 0.02) (-0.18 to 0.01) month change (-0.27 to -0.06) (-0.27 to -0.06) Values expressed as mean (95% CI) unless otherwise indicated

30 Screening Are we defining obesity well?

31 Body fat distribution is more predictive of all cause mortality than overall adiposity Sung Woo Lee et al. Diabet, Obes and Metab participants who underwent abdominal computed tomography (CT) measured body fat. 253 deaths in a 5.7 y follow-up. Kaplan Meier survival curve of tertiles of subcutaneous fat area (SFA) and visceral to subcutaneous fat area ratio (VSR) Increased subcutaneous fat area (SFA) was associated with decreased all cause mortality, whereas an increased visceral fat area (VFA) and visceral to subcutaneous fat area (VSR) were related to increased all cause mortality.

32 Joint association between body fat and its distribution with all-cause mortality: A data linkage cohort study based on NHANES ( ) Bin Dong et al, PLOS One 2018 Data linkage cohort study included 16,415 participants (8554 females) aged 18 to 89 years from National Health and Nutrition Examination Survey III. A total of 4,999 deaths occurred during 19-year follow-up. Association between body fat percentatge and waist-hip ratio with hazard ratio of all-cause mortality in males and females, NHANES % 35% Solid lines and dash lines represent the hazard ratios and their 95% conficence intervals after adjusting for baseline age and ethnicity

33 New indexes of body fat distribution and sex-specific risk of total and cause-specific mortality: a prospective cohort study. Bin Dong et al, PLOS One 2018 Data from the German population based KORA Augsburg cohort study men and 6637 women aged 25 to 74 years with a follow-up period of 15.4 years were included. Body Adiposity Index (hip circumference height 1.5 ) Association between BMI, BAI, WC, WHR, and WHtR and the outcomes all-cause-, CVD-, and cancer mortality using cubic smoothing splines in men

34 New indexes of body fat distribution and sex-specific risk of total and cause-specific mortality: a prospective cohort study. Bin Dong et al, PLOS One 2018 Data from the German population based KORA Augsburg cohort study men and 6637 women aged 25 to 74 years with a follow-up period of 15.4 years were included. Central obesity reflects higher all-cause and CVDmortality risk particularly in women. BAI (body adiposity index) and WHtR seem to be valid as risk predictors for all-cause and especially CVD mortality in men Association between BMI, BAI, WC, WHR, and WHtR and the outcomes all-cause-, CVD-, and cancer mortality using cubic smoothing splines in women

35 Estamos clasificando bien al paciente obeso? Criterios de clasificación del sobrepeso y la obesidad Body mass index classification misses subjects with increased cardiometabolic risk factors related to elevated adiposity. Gómez-Ambrosi J et al Int J Obes 2012 n=6123 r=0.78 r=0.87 p<0.001 IMC= peso (Kg)/ talla (m) 2 29% 20,1-24,9% / 30,1-34,9% (men/women) 25% / 35% (men/women) 80%

36 From the overweight to the overfat (del IMC al % de masa muscular) Estimated number and percentage of overfat and underfat adults and children worldwide (based on 2014 world population numbers of 7.2 billion). 1Includes obese and overweight and other populations listed above (items 1 5). The 62% number does not include item 6 (children). 2 Includes 666 million adults due to starvation, plus 10.8 million chronically ill people who were cachexic at time of death in 2008 (with the high range including 70 million with eating disorders). 3World population of 7.2 billion minus overfat plus underfat.

37 Not only the amount, also fat distribution makes the difference INFLAMMATION...others?

38 Characterization of different fat depots in NAFLD using inflammation-associated proteome, lipidome and metabolome Lovric A et et al, Sci Rep, Sept 2018 Heatmap visualization based on Spearman correlation between variables of interest (column wise) and lipidome (row wise). Different metabolic signatures for different fat depots were identified Colour key indicates strength of a relationship: blue color negative relationship, red colour positive relationship. *Significant relationship after FDR correction and significance level of 0.05.

39 Interventions Primary, secondary, tertiary, community-level

40 La obesidad es una enfermedad multifactorial Efecto HALO Lee B, et al. Nutrition Reviews Vol. 75(S1):94 106

41 Tratamiento integral de la obesidad El objetivo general del tratamiento integral consiste no solo en la reducción exitosa del peso y la grasa corporal, sino en la modificación del estilo de vida para que la pérdida de peso se mantenga a lo largo de los años Mejor conocimiento y definición de la patología Manejo Nutricional Manejo de la actividad física y el ejercicio Manejo psicológico Manejo farmacológico y/o quirúrgico 3. Creación ambiente saludable

42 Prevención primaria de la obesidad Regulación del balance calórico y de nutrientes para prevenir la ganancia de peso corporal Alimentación Actividad física Facilitar el acceso a alimentos saludables Publicidad de los alimentos, etiquetado Control del tamaño de las raciones Asequibilidad de alimentos saludables Pautas para las comidas Tasas Areas seguras para la práctica de la actividad física Urbanismo saludable

43 Tratamiento quirúrgico de la obesidad Tratamiento farmacológico de la obesidad Dra Nuria Vilarrasa Sábado 20 de octubre 8:30-9:00 Dr Juanjo Gorgojo Sábado 20 de octubre 11:00-11:30

44 Estrategias comunitarias 1. TO PROMOTE THE AVAILABILITY OF AFFORDABLE HEALTHY FOOD AND BEVERAGES 2. TO SUPPORT HEALTHY FOOD AND BEVERAGE CHOICES 3. TO ENCOURAGE BREASTFEEDING 4. TO ENCOURAGE PHYSICAL ACTIVITY OR LIMIT SEDENTARY ACTIVITY AMONG CHILDREN AND YOUTH 5. TO CREATE SAFE COMMUNITIES THAT SUPPORT PHYSICAL ACTIVITY 6. TO ENCOURAGE COMMUNITIES TO ORGANIZE FOR CHANGE

45 Future research efforts Filling in gaps, expanding on existing knowledge

46 Los factores implicados, hasta el momento, en la obesidad son:

47 Nutrigenómica-nutrición personalizada

48 Metabolómica de la obesidad

49 Microbiota intestinal

50 Epigenómica de la obesidad

51 Qué pasa cuando se estropea el reloj?

52 Gracias por su atención

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55 On average, the prevalence of overfat adults and children in developed countries is extremely high, and substantially greater than that of overweight and obese individuals

56 Heymsfield SB, Wadden TA. N Engl J Med 2017;376:254-66

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58 Sobrepeso y obesidad infantil: evolución en España Estudio enkid varones y mujeres de entre 2 y 24 años (423 niños entre 6-9 años) ( ) 14,5% sobrepeso/15,9% obesidad 11,8% sobrepeso 18,5% obesidad 30,3% niños y niñas de 6-9 años distribuidos en centros escolares de todas las CC.AA entre ,1% sobrepeso 14,5% obesidad (26,6%) niños y niñas de 6-9 años distribuidos en centros escolares de todas las CC.AA entre

59 Sobrepeso y obesidad infantil: situación en España niños (5.532 niños y niñas) de 6-9 años en 165 centros escolares de todas las CC.AA entre Esta muestra es representativa del conjunto de la población española para esos grupos de edad. 20,4 kg/m 2 20 kg/m 2