Alessandro Alessandro PintoPinto
Alimenti “buoni” e “cattivi”
nella patogenesi e nel
trattamento dell’obesitàLE FRONTIERE DEI DISTURBI DELL'ALIMENTAZIONE
CONGRESSO NAZIONALE SISDCA 2016
Roma, 26-27 Febbraio 2016
Aula magna, 1^ Clinica Medica
Policlinico Umberto I di Roma
Dipartimento di Medicina Sperimentale
Sezione di Fisiopatologia Medica, Scienza
dell’Alimentazione ed Endocrinologia
«alimento»
Reg CE 178/02 “qualsiasi sostanza o prodotto trasformato, parzialmente
trasformato o non trasformato, destinato ad essere ingerito, o di cui si
prevede ragionevolmente che possa essere ingerito, da esseri umani”
«Non sono compresi:
a) i mangimi;
b) gli animali vivi, a meno che siano preparati per l’immissione sul mercato ai fini del consumo umano;
c) i vegetali prima della raccolta;
d) i medicinali ai sensi delle direttive del Consiglio 65/65/CEE (1) e 92/73/CEE (2);
18-65 anni
Alimenti “cattivi” !!!
d) i medicinali ai sensi delle direttive del Consiglio 65/65/CEE (1) e 92/73/CEE (2);
e) i cosmetici ai sensi della direttiva 76/768/CEE del Consiglio (3);
f) il tabacco e i prodotti del tabacco ai sensi della direttiva 89/622/CEE del Consiglio (4);
g) le sostanze stupefacenti o psicotrope ai sensi della convenzione unica delle Nazioni Unite sugli stupefacenti del
1961 e della convenzione delle Nazioni Unite sulle sostanze psicotrope del 1971;
h) residui e contaminanti.”
“Sostanza che, introdotta nell’organismo, è in grado di fornire
energia e nutrienti indispensabili al normale svolgimento di funzioni
fondamentali per l’accrescimento e la vita dell’individuo”. aliménto s. m.
[dal lat. alimentum, der.di alĕre «nutrire»].
A.Bach-Faig et al - Public Health Nutrition: 2011, 14(12A), 2274–2284
Alimenti “buoni”!!!
Come ritiene sia la sua conoscenza
del rapporto alimentazione e salute?%
scarsa 16,0
sufficiente 46,1
83% ha dichiarato di aver ricevuto
informazioni sul tema
97% ritiene di avere uno stile alimentare
mediterraneo
Osservatorio sui consumi alimentari in Italia
Le conoscenze degli adulti !!!
sufficiente 46,1
buona 30,3
ottima 4,3
Non sa/Non Indicato 3,3
Totale 100,0
16% ha seguito una dieta nell’anno precedente
all’intervista
Progetto “Qualità Alimentare”
Indagine Eurisko 2013: più di 7 italiani su 10 dichiarano di mangiare in modo sano, ma solo il 15%
riesce a consumare la giusta quantità giornaliera di frutta e verdura.
% E da cereali, legumi, patate, ortaggi, frutta
fresca/secca, pesce, vino, olio d’oliva
% E da latte, formaggio, carne, uova, grassi
animali, margarina, bevande dolci, torte/biscotti
MAI =
1.Ancora troppa carne.
2.Legumi questi sconosciuti.3.Frutta e verdura: promosse dagli anziani e bocciate dai giovani
4.Ancora mediterranei nonostante tutto. Si conferma in larga parte l’aderenza al modello
alimentare mediterraneo con i cereali come alimenti base, l’olio di oliva come condimento e il vino comealimentare mediterraneo con i cereali come alimenti base, l’olio di oliva come condimento e il vino come
bevanda alcolica
Assunzione di MACRO nutrienti in Italia
Contributo percentuale di macronutrienti rispetto l’assunzione totale di energia in tutto il campione
in studio (0-99 anni), maschi e femmine Survey INRAN-SCAI 2005-06
Il contributo in energia da
macronutrienti conferma che
in Italia, come in altri Paesi
Proteine;
15,7%Lipidi; Alcol; 2,5%
% di energia da macronutrienti
in Italia, come in altri Paesi
industrializzati, l’apporto di
grassi è troppo elevato
mentre quello di carboidrati è
troppo ridotto.
Carboidrati;
45,5%
Lipidi;
36,2%
Acidi grassi saturi 11,2%
Acidi grassi monoinsaturi 17,5%
Acidi grassi polinsaturi 4,5%
Acidi grassi saturi 11,2%
Acidi grassi monoinsaturi 17,5%
Acidi grassi polinsaturi 4,5%
Nutrition, Metabolism & Cardiovascular Diseases (2011) 21, 922e932
di cui zuccheri semplici 15,0%
Nutrition transition and global dietary trend
increased availability
of fast food
unhealthy diets with a high calorie content; large portion sizes; and
large amounts of processed meat, highly refined carbohydrates,
sugary beverages, and unhealthy fats.sugary beverages, and unhealthy fats.
large chain
supermarkets
displace fresh local food and farm shops and serve as a source of
highly processed foods, high-energy snacks, and sugary beverages
in many developed and developing countries
livestock revolutionwhich leads to a rise in the production and consumption of beef,
pork, dairy products, eggs, and poultry
increased refinement
of grain products
milling and processing of whole grains to produce refined grains
such as polished white rice and refined wheat flour reduce the
nutritional content of grains, including their fibre, micronutrients,
and phytochemicals.
The healthy and Western dietary patterns differed
predominantly in fat and sugar intakes and explained 84 % of
the total variance in food intakes
The healthy pattern
• positively correlated with
whole grains, fruit,
vegetables, legumes, fish,
fiber, folic acid, and most
The Western pattern
• high intakes of take-away
foods, red meats, processed
meats, full-fat dairy
products, fried potatoes
Alimenti “cattivi” !!!Alimenti “buoni”!!!
fiber, folic acid, and most
micronutrients,
• inversely correlated with
energy from total fat,
saturated fat, and refined
sugar.
products, fried potatoes
( “ hot chips ” or “ French
fries ” ), refined cereals,
cakes and biscuits,
confectionery, soft drinks,
crisps, sauces, and
dressings.
Wendy H. Oddy, Am J Gastroenterol 2013; 108:778–785
L’obesità in età adulta: indagine Multiscopo dell’Istat “Aspetti Della Vita
Quotidiana. Anno 2009” in Italia nel periodo 2001-2009, è aumentata sia la % di
sovrappeso (dal 33,9% nel 2001 al 36,1% nel 2009) sia di obesità (dall’8,5% nel
2001 al 10,3% nel 2009).
La quota di popolazione in eccesso ponderale passa dal 19% tra i 18-24 anni a
>60% tra 55-74 anni, per poi diminuire lievemente nelle età più anziane (55,9%
>75 anni). Il 45,2% degli uomini è in sovrappeso e l’11,3% è obeso rispetto al
27,7% e al 9,3% delle donne.
Nel 2010 secondo i dati del Sistema Di Sorveglianza PASSI, negli adulti
www.epicentro.iss.it/problemi/obesita/epid.asp
Nel 2010 secondo i dati del Sistema Di Sorveglianza PASSI, negli adulti
sovrappeso 32%, obesità 11% : > 4 adulti su 10 (42%) sono in eccesso ponderale.
Dal confronto con le stime dei tre anni precedenti, nel quadriennio 2007-2010
la prevalenza dell’eccesso ponderale è stabile: 43% nel 2007 e nel 2008, 42% nel
2009 e nel 2010.
Obesity is already responsible for 2–8% of health costs and 10–13% of deaths in
different parts of the Region.
www.euro.who.int/en/what-we-do/health-topics/noncommunicable-diseases/obesity
Distal and proximal causes of obesity
BE. Sansbury and BG. Hill. Free Radic Biol Med. 2014
HypothesizedHypothesized relationshiprelationship betweenbetween
the environment and weight statusthe environment and weight status
obesity reviews (2011) 12, e95–e106
In terms of dietary factors, population trends in overweight and obesity would
suggest that energy intake exceeds energy expenditure.
obesity reviews (2011) 12, e95–e106
Population-based studies have shown that energy-dense diets are characterized by:
lower intakes of foods and nutrients
As there are physiological limitations on the quantity of food/drink that can be
consumed by individuals, excess energy intakes are often the consequence of energy-
dense diets (i.e. high in kilojoules per unit weight).
Population-level dietary estimates show that fat intakes exceed recommendations by at
least 10%, the majority of the population do not consume sufficient fruit, vegetables or
fibre and a significant proportion of the population skip meals.
• higher fat intakes
• greater intakes of energy-dense foods,including takeaway foods
• higher intakes of foods providing‘empty calories’ (e.g. sugar-sweetened drinks)
• lower intakes of foods and nutrientsthat may have appetite-controllingproperties (i.e. fruit and vegetables,fibre)
• meal patterns that interfere with theregulation of energy intakes (e.g.skipping breakfast)
Objectives
To assess the effects of proportion of energy intake from
fat on measures of weight and body fatness (including
obesity, waist circumference and body mass index) in
people not aiming to lose weight, using all appropriate
randomised controlled trials (RCTs) and cohort studies in
adults, children and young people.
Authors’ conclusions
Trials where participants were randomised to a lower
fat intake versus usual or moderate fat intake, but
with no intention to reduce weight, showed a
consistent, stable but small effect of low fat intake on
body fatness: slightly lower weight, BMI and waist
circumference compared with controls.
Greater fat reduction and lower baseline fat intakeGreater fat reduction and lower baseline fat intake
were both associated with greater reductions in
weight.
This effect of reducing total fat was not consistently
reflected in cohort studies assessing the relationship
between total fat intake and later measures of body
fatness or change in body fatness in studies of
children, young people or adults.
obesity reviews (2011) 12, e95–e106
1. Accessibility and availability. Increasing access to stores that promote
unhealthy food choices: takeaway and fast food shops, convenience stores and
other outlets that are less likely to sell healthy food choices.
2. Social conditions. These arise from inter-personal interactions (e.g.
marketing) and social support; living in a socioeconomically-deprived area was
‘Obesogenic’ food
environments
marketing) and social support; living in a socioeconomically-deprived area was
the only environmental factor consistently associated with a number of
obesogenic dietary behaviours.
3. Material conditions. Including unfavourable working, housing and
neighbourhood conditions (e.g. neighbourhood deprivation).
The environment may play an important role in the development of
overweight/obesity, however the dietary mechanisms that contribute to this remain
unclear and the physical activity environment may also play an important role in weight
gain, overweight and obesity.
Although many methodological differences among the studies performed to date
currently limit the ability to make comparisons, the results suggest there is a positive
relationship between the consumption of food away from home and weight gain.
‘Obesogenic’ food
environments
Many factors influence our dietary choices, including the expert marketers who advise
manufacturers on ways to encourage the population to buy more, especially
profitable, palatable ‘ultra-processed’ foods.
Supermarket ‘Bullying’
Findings from this review suggest that while a causal relationship cannot be stated, an
unequivocal association exists between increased fast food consumption and increased
caloric intake making individuals much more susceptible to weight gain and obesity.
Furthermore, in a recent publication by the World Cancer Research Fund and American
obesity reviews (2008) 9, 535–547
Furthermore, in a recent publication by the World Cancer Research Fund and American
Institute for Cancer Research, the expert panel found the current literature regarding fast
food consumption as a cause of weight gain, overweight and obesity strong and
consistent, resulting in recommendations for minimal fast food consumption.
While a plausible biological mechanism is present, many findings are subject to
interpretation bias as many methodological issues such as small sample size, short
duration of follow-up, inconsistency and repeatability of measurement of exposure
variables, in addition to inherent confounding by other lifestyle modifications, are
present among the published manuscripts.
• large portion size,
• high glycemic load,
• excessive amounts of refined starch and added sugars,
• the most cogent and comprehensive hypothesis is the energy density of fast food
Many plausible biological
mechanisms:obesity reviews (2008) 9, 535–547
• Humans possess a weak innate ability to recognize foods that are energy dense and
down-regulate the bulk of food eaten accordingly, […] such compensation was
insufficient as total caloric intake still increased substantially.
• The ability of energy dense food to interfere with appetite regulation may be
exacerbated in obese individuals and children.
• Obese individuals were unable to sufficiently adjust their caloric intake after a fast food
meal in comparison with lean individuals.
• Children are also suspected to be especially vulnerable to high energy density meals
because they have not yet developed the necessary cognitive dietary restraint .
• Traditional societies consumed largely unprocessed plant based diets that were
high in fiber and included whole grains, legumes and nuts as staples. These diets
There was consensus that diets low
in GI and GL were relevant to the
prevention and management of
diabetes and coronary heart
disease, and probably obesity.
high in fiber and included whole grains, legumes and nuts as staples. These diets
were low GI and low GL.
• The shift away from traditional diets to western highly processed diets has
paralleled a dramatic rise in the prevalence of diabetes, obesity and CVD.
• Epidemiological studies indicate that the consumption of plant-based diets reduce
risk of T2DM and CHD.
• The “fiber hypothesis” suggested that this was a direct effect of fiber. The GI
concept is an extension of the fiber hypothesis suggesting that fiber would reduce
the rate of nutrient influx from the gut.
• It has particular relevance to those chronic Western diseases associated with
central obesity and insulin resistance .
Methods: We followed-up 9 267 Spanish university graduates for a mean period of 5 years. Dietary
habits at baseline were assessed using a semi-quantitative 136-item food-frequency questionnaire.
Average yearly weight change was evaluated according to quintiles of baseline glycemic index,
glycemic load, and categories of bread consumption. We also assessed the association between
bread consumption, glycemic index, or glycemic load, and the incidence of overweight/obesity.
Background: To evaluate prospectively the
relationship between white, or whole grain
bread, and glycemic index, or glycemic load
from diet and weight change in a
Mediterranean cohort.
bread consumption, glycemic index, or glycemic load, and the incidence of overweight/obesity.
Conclusions
Despite evidence that low-GI and/or low-GL diets are independently associated with a
reduced risk of certain chronic diseases, our results suggest that dietary GI and dietary
GL were not associated with increased weight gain or an increased risk of
overweight/obesity development in a Mediterranean cohort of young adults with a low
average BMI and with a high intake of fruits and vegetables. In contrast, a high
consumption of white bread was a risk factor for overweight/obesity in the same
population. However, further studies, in special intervention studies, are needed before
including these measures in the dietary recommendations for healthy populations.
Aim: The aim of the present meta-
analysis was to investigate the long-term
effects of glycemic index-related diets in
the management of obesity with a
special emphasis on the potential
benefits of low glycemic index/load
(GI/GL) in the prevention of obesity-
associated risks.
Outcome of interest markers included anthropometric data as well as biomarkers of CVD and
glycemic control. 14 studies were included in the primary meta-analysis. Weighted mean
differences in change of C-reactive protein [WMD: 0.43 mg/dl, (95% CI 0.78 to 0.09), p Z 0.01], and
fasting insulin [WMD: 5.16 pmol/L, (95% CI 8.45 to 1.88), p Z 0.002] were significantly more fasting insulin [WMD: 5.16 pmol/L, (95% CI 8.45 to 1.88), p Z 0.002] were significantly more
pronounced in benefit of low GI/GL diets.
However decrease in fat free mass [WMD: 1.04 kg (95% CI 1.73 to 0.35), pZ0.003] was significantly
more pronounced following low GI/GL diets as well.
No significant changes were observed for blood lipids, anthropometric measures, HbA1c and fasting
glucose.
Decreases in C-reactive protein and fasting insulin remained statistically significant in the low GI/GL
subgroups.
Conclusions: The present systematic review provides evidence for beneficial effects of
longterm interventions administering a low glycemic index/load diet with respect to
fasting insulin
Ecological observations which have linked increasing fructose intake with increasing
obesity and diabetes rates along with animal models and select human trials of
fructose overfeeding at levels of exposure far beyond actual population levels of
intake have driven this debate.
Fructose the low-GI sugar: is there
cause for concern?
intake have driven this debate.
Although large prospective cohorts studies have shown significant positive
associations with incident obesity, diabetes, gout, CHD, and stroke when comparing
the highest with the lowest levels of intake of sugar sweetened beverages, these
associations do not hold true at moderate levels of intake or when modeling total
fructose (with the exception of gout). Similarly, the evidence from controlled
feeding trials shows that there is a reasonable body of consistent evidence from
controlled feeding trials that fructose in isocaloric exchange for other sources of
carbohydrate at low-to-moderate doses near the average U.S. intake of fructose
(10% total energy) does not have adverse effects.
Ann Intern Med. 2012;156:291-304.
Study Selection: At least 3 reviewers identified controlled feeding trials lasting 7 or more days that
compared the effect on body weight of free fructose and nonfructose carbohydrate in diets
providing similar calories (isocaloric trials) or of diets supplemented with free fructose to provide
excess energy and usual or control diets (hypercaloric trials). Trials evaluating high-fructose corn
syrup (42% to 55% free fructose) were excluded.
Data Synthesis: Thirty-one isocaloric trials (637 participants) and 10 hypercaloric trials (119Data Synthesis: Thirty-one isocaloric trials (637 participants) and 10 hypercaloric trials (119
participants) were included; studies tended to be small (15 participants), short (12 weeks), and of
low quality. Fructose had no overall effect on body weight in isocaloric trials (mean difference, 0.14
kg [95% CI, 0.37 to 0.10 kg] for fructose compared with non fructose carbohydrate). High doses of
fructose in hypercaloric trials (104 to 250 g/d, 18% to 97% of total daily energy intake) lead to
significant increases in weight (mean difference, 0.53 kg [CI, 0.26 to 0.79 kg] with fructose).
Limitations: Most trials had methodological limitations and were of poor quality. The weight-
increasing effect of fructose in hypercaloric trials may have been attributable to excess energy
rather than fructose itself.
Conclusion: Fructose does not seem to cause weight gain when it is substituted for other
carbohydrates in diets providing similar calories. Free fructose at high doses that provided excess
calories modestly increased body weight, an effect that may be due to the extra calories rather
than the fructose.
obesity reviews (2013) 14, 606–619
Among numerous potential dietary determinants of obesity, sugar-sweetened
beverages (SSBs) have recently received a great deal of attention, because they are
the largest source of calories and added sugars in both children and adults in the the largest source of calories and added sugars in both children and adults in the
United States.
Consumption of SSBs has increased dramatically in the past several decades among
both children and adults.
Additionally, SSBs have been clearly identified as a suitable target for public health
interventions, not only because SSB consumption is strongly associated with obesity,
but also because they offer only ‘empty’ calories and provide almost no nutritional
value.
obesity reviews (2013) 14, 606–619
Conclusions
Consumption of SSBs has increased markedly across the globe in recent decades, tracking closely Consumption of SSBs has increased markedly across the globe in recent decades, tracking closely
with the growing burdens of obesity. These beverages are currently the largest source of added
sugar intake and the top source of daily energy in the U.S. diet. The cumulative evidence from
observational studies and experimental trials is sufficient to conclude that regular consumption of
SSBs causes excess weight gain and these beverages are unique dietary contributors to obesity and
T2D. Compelling evidence indicates that reducing SSBs will have significant impact on the
prevalence of obesity and its related diseases, especially T2D. Despite strong resistance from the
beverage industry, several public policies and regulatory strategies to reduce intake of SSBs are
already in place or being developed. The combination of public health campaigns and regulations
and laws is needed to change social norms and dietary behaviours. Although reducing SSB
consumption alone is unlikely to solve the obesity epidemic entirely, limiting intake of SSBs is one
simple change that could have a measurable impact on weight control and prevention of T2D and
other metabolic diseases.
Take home messages
1. Il peggior nemico della salute è la disinfomazione!!!
2. La transizione verso un modello alimentare di tipo occidentale (alimentazione
iperlipidica, associata ad un eccessivo consumo di zuccheri semplici, cereali raffinati, alimenti di
origine animale, bevande zuccherate; scarso apporto di fibra e basso consumo di frutta, ortaggi,
legumi e pesce) risulta associata ad un’amentata prevalenza di obesità.
3. Il rischio di obesità è associato all’interazione tra un ambiente che promuove la
sedentarietà e un “ambiente alimentare obesiogeno” (fast food, takeaway, pasti
frequenti fuori casa, alimenti ad alta densità energetica nella grande
distribuzione).
4. Una dieta iperlipidica è associata ad un modesto ma significativo incremento4. Una dieta iperlipidica è associata ad un modesto ma significativo incremento
ponderale.
5. Il ruolo dell’indice glicemico non è stato chiarito, sebbene una dieta a basso
indice glicemico risulti associata ad un minore rischio di complicanze associate
all’obesità (riduzione PCR e insulinemia).
6. Il consumo di fruttosio è associato ad aumentato rischio di obesità e di steatosi a
dosaggi elevati, ma non a dosaggi adeguati.
7. Il largo consumo di bevande zuccherate costituisce un fattore di rischio
univocamente riconosciuto per l’obesità.
Alessandro Pinto