Eating behavior & obesity. Thasinas Dissayabutra, M.D, Ph.D.

Transcription

1 Eating behavior & obesity Thasinas Dissayabutra, M.D, Ph.D.

2 What are importances in eating Obesity (definition, etiology, classification, pathogenesis, complication, prevention) Regulation of appetite Body mass index Leptin Eating disorders : anorexia nervosa, bulimia nervosa

3 What is health promotion Definition Categories Primary Secondary Tertiary Health promotion in simple obesity

4 What you should know in nutrition Body mass index Obesity Eating disorders Anorexia nervosa Bulimia nervosa Binge-eating habit

5 Do you know exactly who you are? Prader-Willi syndrome

6 Are these your desired shape?

7 How Body mass to determine index is universal about shape indicator

8 Simple obesity

9 Simple obesity Definition obesity without endocrine or genetic disease Diagnosis of obesity : 1. Weight for height > 120% or 2. BMI > 95 th percentile Etiology : imbalance of energy intake and expenditure 1. High energy diet 2. Low physical activity (Sedentary lifestyle) 3. Virus?

10 Obesity is a critical health problem

11 Obesity is a critical health problem

12 Obesity in South and Southeast Asia

13 Obesity in South and Southeast Asia

14 Obesity in Thailand Children 13.4% Adolescent 10.2% Adult 29.2% Elderly 23.9% Prevalence was increasing as the same rate as Western country in the last decade

15 Body mass index (BMI) BMI = Wt(kg) Ht(m) 2 Male = kg/m 2 Female = kg/m 2

16 Body mass index (BMI) for children

17 Body mass index (BMI) for men

18 Body mass index (BMI) for women

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22 Factors influence obesity ป จจ ยภายใน ป จจ ย ภายนอก (Obesogenic environment) การได ร บพล งงานเก น 1. Genetic background 2. Environmental โรคท ก อให เก ดความผ ดปกต ของการ stimuli 3. Developmental ควบค มความร ส กอยากอาหาร processes เช น diabetes type 2, Pradle-Willi syndrome, Diencephalic syndrome, Glucocorticoid excess, Leptin resistance ภาวะจ ตใจผ ดปกต เช น เคร ยด การเข าถ งอาหารท ม พล งงานส งได ง าย ประเพณ ว ฒนธรรม ความเช อ ถ นท อย อาศ ย ยาบางชน ด เช น cyproheptadine, insulin การลดการใช พล งงาน โรคท ม ผลท าให basal metabolic rate ลดลง เช น hypothyroidism, leptin deficiency, leptin receptor deficiency Sedentary lifestyle การขาดการออกก าล งกาย

23 Thrifty genotype

24 Thrifty genotype

25 Thrifty genotype

26 Ob-gene and leptin

27 Leptin Ob-gene found by Zhang et al, in 1994 from mutant ob/ob mice, and is it encode a peptide called leptin, comprised of 167 amino acid, produced by white adipose tissue, molecular weight 16 Kd and half life 75 minutes. Its name came from leptos means thin Leptin secretion is up-regulated by TNF, insulin and cortisol, down-regulated by catecholamine, norepinephrine and epinephrine

28 Leptin receptors Leptin receptors are encoded by db-gene. Leptin receptors have several alternatively forms, it can be divided into extracellular domain and intracellular domain. The intracellular domain has variety form while the extracellular domain is constant. Leptin receptor functions in transport leptin across bloodbrain-barrier and triggers a jak2-stat3- tyrosine kinase intracellular second messenger

29 Leptin receptors

30 Leptin action in body weight regulation Decrease appetite by inhibit NPY and stimulate POMC at hypothalamus Increase metabolic rate Increase muscle cell energy expenditure Increase activity level Increase body temperature Upregulate fatty acid oxidation enzyme in nonadipose cell Modulate body hormones : stimulate thyroid and sex hormones release and inhibit corticotropin releasing hormone

31 Leptin action on hypothalamus

32 Leptin action in body weight regulation

33 Leptin action in body weight regulation Plasma leptin level and mrna content of leptin in fat cell correlate well with the BMI and estimated fat mass of humans Leptin normally higher in women than men Leptin level relates with %body fat rather than genetic background in identical twin Leptin signals the recent (over several days) states of fasting or feeding

34 Leptin action in body weight regulation A single meal has little effect on plasma leptin level Plasma level decrease after 60 years of age Leptin level is low in anorexia nervosa women Leptin level is high in Prader-Willi syndrome There is diurnal variation in plasma level Leptin has direct effect in attenuating insulin activities and downregulating gluconeogenesis in hepatocyte cell culture

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36 Leptin in regulation of body weight

37 Leptin in obesity

38 Leptin and leptin receptor deficiency Arrested onset of puberty Depressed thyroid function Increase glucocorticoid secretion Decrease energy expenditure of fat cells Prototypic defect ob- and db-gene mice have hyperphagia, obesity, diabetes, defective thermogenesis, hypogonadotropic hypogonadism, infertility

39 Regulation of appetite

40 Regulation of appetite

41 Appetite control system 1. Central appetite regulation (hypothalamic system) Factor trigger hunger and satiety center (glucose) Neurotransmitter : serotonin Orexigenic neuropeptide : NPY, Agouti-related protein (AgRP) Anorexigenic neuropeptide : melanocortin, -MSH, cocaine- and amphetamine-regulated transcript (CART) 2. Peripheral hormone regulating appetite Insulin Adipose hormones : leptin Gut hormones : Ghrelin, Peptide YY, glucagon-likepeptide-1, CCK, etc.

42 Hunger and satiety center in hypothalamus Increase plasma glucose Feeding Eating Ventromedial hypothalamus (Satiety center ) Lateral hypothalamus (Hunger center ) Stop eating Fasting Decrease plasma glucose

43 Central appetite control

44 Orexigenic and anorexigenic peptides Stimulate (orexigenic) Neuropeptide Y (NPY) Agouti-related peptide (AGRP) Melanin concentrating hormone (MCH) Orexin A, B (hypocretin 1,2) Ghrelin Cortisol Galatin Norepinephrin Inhibit (anorexigenic) Leptin Insulin -melanocyte-stimulating hormone ( -MSH) CRH Cocaine-amohetamine-regulate transcript (CART) Cholecystokinin (CCK) Interleukin-1b Enterostatin Calcitonin Amylin Urocortin, glucagon-like peptide 1, oxytocin, neurotensin, Serotonin

45 Orexigenic hypothalamic peptide Neuropeptide Y (NPY) NPY is a very potent stimulator for food seeking and an inhibitor of energy expenditure Agouti-related peptide (AgRP) AgRP is a 131 amino acid protein acts as an endogenous antagonist that acts on MC 4 R (melanocortin-4 receptor : a hypothalamic receptor for the anorexigenic peptide -MSH), secrete by specialized cell and melanocyte reside near each other in the skin.

46 Anorexigenic hypothalamic peptide Melanocortin ( -MSH) Derived from the precursor pro-opiomelanocortin (POMC) molecule via tissue-specific post-translational cleavage. MC3 and MC4 receptors are biologically unique in that there is an endogenous antagonist of AgRP in addition to endogenous agonists of melanocortin. Central injection of -MSH inhibits feeding and reduces body weight in mice. POMC is co-expressed in arcuate neurons with cocaine and amphetamine-regulated transcript (CART) which directly stimulate leptin

47 Anorexigenic hypothalamic peptide Serotonin (5-HT) Serotonin is a short-acting widespread neurotransmitter which acts on a number of receptor. In general, agonists at the 5-HT receptors and drugs that inhibit the reuptake of serotonin reduce feeding. Additionally, 5-HT stimulates noradrenaline release and modifies behavior and mood. Agonists at the 5-HT 2C receptor show the most consistent inhibition of food intake and the 5-HT2C knock-out mice is hyperphagic and obese.

48 Factors influence eating habit 1. Nature Regulation of appetite : reduced plasma glucose, decrease hepatic fat oxidation Energy storage/weight set point vs. Age 2. Nurture Culture Environment e.g., weather, emotion Biological factors : palatability, metabolic state Other non-biological factors : cost, convenient, social circumstances

49 Thrifty genotype In the history, human fight for food stenuously, fasting and femine were constant. Genotypes were selected to favor energy storage In the current period, plentiful and easily accessible high-caloric food and the convenient, sedentary lifestyle within last 30 years cannot allow the significant change of genetic pool So, the prevalence of obesity is increasing in dramatic rate in last three decades

50 Morbidity in obesity (complication) 1. DM type 2 and insulin resistance syndrome 2. Hypertension, hyperlipidemia, metabolic syndrome and cardiovascular diseases 3. Respiratory (obstructive sleep apneu, asthma) 4. Precoccious puberty 5. Degenerative joint disease 6. Proteinuria 7. Cancer 8. Infertility 9. Exercise intolerance 10. Psychological problems

51 Obesity in U.S.A.

52 Morbidity in obesity

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56 Waist circumference and Waist-Hip Ratio Used for diagnosis of central obesity Normal waist in male female < 40 inches (102 cm) < 35 inches (88 cm) Waist-Hip ratio male < 0.9 female < 0.85 Predictive value for CVD > 0.5 Correlate with diabetes mellitus, insulin resistance, cardiovascular diseases, Alzheimer s disease Pariek et al, 2007

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58 Skinfold thickness measurement Highest sensitive in body fat distribution measurement 3-7 sites measurement required, rightsided preferable, 1 cm of skinfold depth Common main sites: triceps, biceps, subscapular, supraspinale, abdominal, thigh, calf excellent good average below average poor Normal Male Female Athletic Male Female

59 Metabolic syndrome (Syndrome X) Comprised of 1. Overweight/Obesity (BMI > 85 th percentile) 2. Blood pressure > 95 th percentile for age 3. Fasting blood glucose > 100 (DM type 2 or insulin resistance syndrome) 4. Hypertriglyceridemia 5. Low HDL Diagnosis uses 3 or more items

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61 Morbidity resolve after weight reduction

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64 Health promotion

65 What is health promotion subclinical clinical disability Healthy Death anatomical change functional change physiological change Biochemical change

66 Classification of health promotion 1. Primary health promotion : disease prevention The best health promotion in all aspects Education is the one of the best PHP 2. Secondary health promotion : early detection and promply treatment Limit severity, comorbidity, contagibility, disability Have the patient rapid and full recovery 3. Tertiary health promotion : rehabilitation Increase quality of life (QOL) Give patient nearly normal lifestyle as possible

67 Health promotion in obesity 1. Primary health promotion : how to prevention What is the best primary promotion in obesity? What time is suitable for start obesity prevention? 2. Secondary health promotion : early detection and promply treatment How to detection? What is the best treatment for obesity? Is anti-obesity agent effective in weight control? 3. Tertiary health promotion What is the THP in obesity

68 Health promotion in obesity 1. Primary health promotion : how to prevention Education is the best Start since the childhood, school age is recommended 2. Secondary health promotion : early detection and promply treatment Evaluate many indicators The best treatment comprises of diet control, exercise and family support Anti-obesity agent is not recommended 3. Tertiary health promotion : prevent relapsing

69 Health promotion in obesity 1. Diet Carbohydrate (60%) : complex carbohydrate Lipid (25%) : SFA:MUFA:PUFA 1:1:1 Chol < 300 mg/day Protein (15%) : high bioavailability protein Fiber-rich fruits, vegetables, and whole grains (14 g/1,000 Kcal) Calories : Kcal/day or less

70 Food recommendation

71 Health promotion in obesity 2. Exercise To help manage body weight and prevent gradual, unhealthy body weight gain in adulthood: Engage in approximately 60 minutes of moderate- to vigorous-intensity activity on most days of the week while not exceeding caloric intake requirements. To sustain weight loss in adulthood: Participate in at least 60 to 90 minutes of daily moderate-intensity physical activity while not exceeding caloric intake requirements.

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73 Anorexia nervosa (AN) DSM IV criteria for diagnosis AN include Intense fear of becoming obese, which does not diminish as weight loss progresses Disturbance in the way in which one s body weight, size, or shape is experienced Refusal to maintain body weight over a minimal normal weight for age and height (below 15% expected) Female, absence of at least three consecutive menstrual cycles without other cause AN was found about 1 in every 100 especially in yr old females, female : male ratio about 10:1. Serotonin abnormality claimed to be the etiology with family history of very competitive, demanding and perfectionis.

74 Anorexia nervosa

75 Bulimia nervosa (BN) DSM-IV criteria for diagnosis include Recurrent episode of binge eating (rapidly consume of large amount of food in a discrete period of time, usually less than 2 hours) During the eating binges, a fear of not be able to stop eating Regularly engaging in self-induced vomiting A minimum average of two binge eating episode per week for at least 3 mo Self evaluation is unduly influenced by body weight and shape, but the distyrbance does not occur exclusively during AN episode BN was more common than AN

76 Bulimia nervosa

77 Binge eating disorder (compulsive overeating) Loss of control during eating large amounts of food in a short amount of time, but not follow by purging method or another way to attempt and control weight

78 Bezoar An accumulation of exogenous matter in the stomuch or intestine due to eating indigestible material such as dirt, stones, hairs, metals. Mostly found in female with underlying personality disorder or neurologically impaired individuals. Bezoars cause in gastric outlet obstruction and gastric perforation

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