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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