Vincenzo Bacci, MD, Vincenzo Bacci, MD, FACEFACE

Our topics for today

Mediterranean diet: tradition and Mediterranean diet: tradition and healthhealth

Carbohydrates: the winners in Carbohydrates: the winners in ItalyItaly

Obesity: an ongoing battleObesity: an ongoing battle Obesity: the Italian weaponsObesity: the Italian weapons

Our topics for today

Mediterranean diet: Mediterranean diet: tradition and healthtradition and health

Carbohydrates: the winners in ItalyCarbohydrates: the winners in Italy Obesity: an ongoing battleObesity: an ongoing battle Obesity: the Italian weaponsObesity: the Italian weapons

MeditMediterraneanerranean DietDiet? ? In 1000 BC…In 1000 BC… Diet Diet - from - from = lifestyle= lifestyle Mediterranea - from Mediterranea - from MEDITERRANEVSMEDITERRANEVS = (sea) in the middle = (sea) in the middle

of landsof lands

lifestyle and nutritional habits developed over the centuries by the populations that originated Greek e Roman civilizations

MediMediterranean terranean DietDiet : : in 1970… in 1970…

In the 50’s and 60’s Ancel e In the 50’s and 60’s Ancel e Margaret KeysMargaret Keys, make the first , make the first observation on nutrition and observation on nutrition and health on the southern Italy and health on the southern Italy and Crete populationsCrete populations

““Seven Countries Study - How to Seven Countries Study - How to eat well and stay well - The eat well and stay well - The Mediterranean Diet” is published Mediterranean Diet” is published in in 1977.1977.

Mediterranean region: common Mediterranean region: common features and differencesfeatures and differences

In the Mediterranean region In the Mediterranean region mortality and mortality and cardiovascular morbidity are lower cardiovascular morbidity are lower than other than other western regionswestern regions

In general the eating pattern is balanced and similar to In general the eating pattern is balanced and similar to the the theoretical cardioprotective compositiontheoretical cardioprotective composition

On the other hand we observe important differences in On the other hand we observe important differences in socioeconomic conditions, traditional eating habits and socioeconomic conditions, traditional eating habits and recent trends in the different countries of the area.recent trends in the different countries of the area.

MediMediterranean terranean DietsDiets: at lest three : at lest three different stylesdifferent styles Spain, Greece, South-Spain, Greece, South-

central Italycentral Italy Cereals, olive oil, fibers, Cereals, olive oil, fibers,

little animal fat (cheese)little animal fat (cheese) France:France:

Abundant animal fats Abundant animal fats (butter, cheeses, foi gras), (butter, cheeses, foi gras), red wine (French paradox )red wine (French paradox )

Middle East, North Middle East, North Africa:Africa: Grains (couscous, rice) Grains (couscous, rice)

legumes, nuts, no alcohollegumes, nuts, no alcohol

The food prejudice map

Google:…..sono conosciuti per + gastronomia *

http://www.peperosso.info/index.php/story/2006/01/20/the_food_prejudice_italian_map

Health in Italy:Life expectancy at birth - 2006

81.480.3

79.979.979.8

79.478.7

7872.9

71.668.6

65.9

65 70 75 80 85

JapanCanada

ItalyFranceSpain

GreeceUK

USAChinaEgyptIndia

Russia

Health in Italy:Life expectancy at birth - 2012

Health in Italy: life expectancy 2011 estimate

ITALYITALY Life expectancy at birth: total population: Life expectancy at birth: total population:

81.8 years81.8 years male: 79.2 yearsmale: 79.2 years female: 84.5 years female: 84.5 years

USA USA Life expectancy at birth: total population: Life expectancy at birth: total population:

78.4 years78.4 years male: 75.9 yearsmale: 75.9 years female: 80.9 years female: 80.9 years

Source: Indexmundi.com

EU Cardiovascular mortality 2004-2008

EU cancer mortality 2004-2008

Not a dietNot a diet Rather, lifestyle with frugal eatingRather, lifestyle with frugal eating Mostly disappeared due to the Mostly disappeared due to the

internationalization and globalizationinternationalization and globalization Many really traditional dishes now Many really traditional dishes now

emarginated emarginated Energy expenditure drastically reducedEnergy expenditure drastically reduced

Mediterranean diet: pleasure wellbeing culture

An example of disappearance of the mediterranean lifestyle and its benefits: Crete 1986 Active lifestyle: 15 Km daily walkingActive lifestyle: 15 Km daily walking Traditional dietTraditional diet Mean weight of a Cretan man 63 KgMean weight of a Cretan man 63 Kg Longevity (life exp. 78 and 81 years)Longevity (life exp. 78 and 81 years) Low cardiovascular diseasesLow cardiovascular diseases

An example of disappearance of the mediterranean lifestyle and its benefits: Crete 2009 Sedentary lifestyle: driving…Sedentary lifestyle: driving… Unhealthy dietUnhealthy diet Mean weight of a Cretan man 83 KgMean weight of a Cretan man 83 Kg Increasing morbid obesityIncreasing morbid obesity higher cardiovascular diseaseshigher cardiovascular diseases

Mediterranean pyramid ? Plate?… or a temple?

www.piramideitaliana.it

The Mediterranean Diet Temple

Sparingly

“bearing” foods

Condiments and wine

Mediterranean diet cultural heritage

Since 2010 the Mediterranean Since 2010 the Mediterranean

diet is included in the UNESCO diet is included in the UNESCO

list celebrating the world's list celebrating the world's

"intangible cultural heritage”"intangible cultural heritage” It encompasses more than just food. It encompasses more than just food. It promotes social interaction, It promotes social interaction, it has given rise to a considerable body of it has given rise to a considerable body of

knowledge, songs, maximsknowledge, songs, maxims It is rooted in respect for the territory and It is rooted in respect for the territory and

biodiversity biodiversity

Mediterranean diet: tradition and healthMediterranean diet: tradition and health Carbohydrates: the winners in ItalyCarbohydrates: the winners in Italy Obesity: an ongoing battleObesity: an ongoing battle Obesity: the Italian weaponsObesity: the Italian weapons

Our topics for today

Carbohydrates in the Mediterranean diet: many healthy features

Starches:(calories, fibers, no fats)Starches:(calories, fibers, no fats) Cereals (pane, pasta)Cereals (pane, pasta) Legumes (peas, beans)Legumes (peas, beans)

Vegetables:(fibers, water, volume, Vegetables:(fibers, water, volume, minimal calories, no fats, antioxidants)minimal calories, no fats, antioxidants)

Fruits :(fibers, water, volume, few Fruits :(fibers, water, volume, few calories, no fats)calories, no fats)

Carbs in the traditional Italian diet

Calories about 60%Calories about 60% Simple carbs 10-12%Simple carbs 10-12%

Mostly fructose in fruitsMostly fructose in fruits Complex carbs in high fiber foodsComplex carbs in high fiber foods Usually good glycemic indexUsually good glycemic index

Legumes with soluble fibersLegumes with soluble fibers Pasta al dentePasta al dente Scarce consumption of potatoes Scarce consumption of potatoes

in Southern Italy in Southern Italy

The Mediterranean Diet Temple: carbohydrates

Sparingly

“bearing” foods

Condiments and wine

Changes in Italy: the last century

NovecentoBertolucci 1976

The Italian diet in 1900: high calories

High energy consumption: >3000 cal/dayHigh energy consumption: >3000 cal/day

Miseria e nobilta’ (Toto’) 1954

The Italian diet in 1900: high carbs, high calories

Poor income: Poor income: grains derivatives and legumesgrains derivatives and legumes were cheap sources of proteins and calories were cheap sources of proteins and calories with a good aminoacid combinations with a good aminoacid combinations (“pasta e fagioli”(pasta and beans))(“pasta e fagioli”(pasta and beans))

Amarcord (Fellini) 1973

The Italian diet in 1900: high carbs, high calories

Pane e acqua (= bread Pane e acqua (= bread and water) in prisonersand water) in prisoners

Pane e olio / bruschetta Pane e olio / bruschetta (bread and oil) in (bread and oil) in peasantspeasants

Pater noster…Panem Pater noster…Panem nostrum cotidiánum da nostrum cotidiánum da nobis hodie = Our nobis hodie = Our Father… Give us this Father… Give us this day our daily breadday our daily bread

Bread up to 90% of caloriesBread up to 90% of calories (10% “companatico” = other food with bread)(10% “companatico” = other food with bread)

Toto’

The Italian diet in 2000: lower carbs

Today low energy expenditure (sedentary Today low energy expenditure (sedentary white collar, falsely hyperactive executive, even white collar, falsely hyperactive executive, even modern agricultural worker) and abundance of modern agricultural worker) and abundance of cheap foodcheap food

Bread, pasta and legumesBread, pasta and legumes considered a bad considered a bad choice in a diet which must have limited caloric choice in a diet which must have limited caloric intakeintake

A portion of steak supplies essential aminoacids A portion of steak supplies essential aminoacids with 150 calories as 100 g of with 150 calories as 100 g of breadbread (290 cal) or (290 cal) or beansbeans (280 cal) (280 cal)

Trends in food consumption

United States: The Revis family of North Carolina Food expenditure for one week: $341.98

Italy: The Manzo family of SicilyFood expenditure for one week: 214.36 Euros or $260.1

Trends in food consumption in Italy - 1

Caloric intake: decreasingCaloric intake: decreasing From 2,600 cal in 1960 to 2,200 nowFrom 2,600 cal in 1960 to 2,200 now

Starch: high consumptionStarch: high consumption 122 Kg vs 89 Kg a year in Europe122 Kg vs 89 Kg a year in Europe 28 Kg pasta28 Kg pasta

Fish: increasingFish: increasing From 13 Kg in 1980 to 21 Kg nowFrom 13 Kg in 1980 to 21 Kg now

Fruits and vegetables (incl. cereals and grains: Fruits and vegetables (incl. cereals and grains: increasingincreasing From 150 Kg in 1950 to 360 Kg nowFrom 150 Kg in 1950 to 360 Kg now Only Greeks have higher consumptionOnly Greeks have higher consumption

Caloric consumption in Italy

Trends in food consumption in Italy - 1

Caloric intake: decreasingCaloric intake: decreasing From 2,600 cal in 1960 to 2,200 nowFrom 2,600 cal in 1960 to 2,200 now

Starch: high consumptionStarch: high consumption 122 Kg vs 89 Kg a year in Europe122 Kg vs 89 Kg a year in Europe 28 Kg pasta28 Kg pasta

Fish: increasingFish: increasing From 13 Kg in 1980 to 21 Kg nowFrom 13 Kg in 1980 to 21 Kg now

Fruits and vegetables (incl. cereals and grains: Fruits and vegetables (incl. cereals and grains: increasingincreasing From 150 Kg in 1950 to 360 Kg nowFrom 150 Kg in 1950 to 360 Kg now Only Greeks have higher consumptionOnly Greeks have higher consumption

Trends in food consumption in Italy 2

Sweets: low consumptionSweets: low consumption 25 kg vs 58 Kg in UK25 kg vs 58 Kg in UK Sugar 24 kg vs 32 kg in EuropeSugar 24 kg vs 32 kg in Europe

Milk: low consumptionMilk: low consumption 57 L vs 93 L in Europe57 L vs 93 L in Europe

Alcohol: decreasingAlcohol: decreasing From 16 L in 1970 to 6.9 L nowFrom 16 L in 1970 to 6.9 L now Wine from 104 L in 1952 to 52 L in 2002Wine from 104 L in 1952 to 52 L in 2002 Beer from 4 L in 1952 to 30 L in 2002Beer from 4 L in 1952 to 30 L in 2002

Alcohol in Italy

Alcohol in Italy (1)

18.6% of youngsters age 11-15 drink 18.6% of youngsters age 11-15 drink alcohol regularly, often binge drink on alcohol regularly, often binge drink on weekendsweekends

Higher consumption in Emilia and Higher consumption in Emilia and Veneto; lower in Campania and CalabriaVeneto; lower in Campania and Calabria

20% of teenagers get intoxicated on 20% of teenagers get intoxicated on weekends (ISTAT survey 2007)weekends (ISTAT survey 2007)

Alcohol in Italy (2) 19.7% of boys and 15.3% of 19.7% of boys and 15.3% of

girls under 15 had at least one girls under 15 had at least one alcoholic drink in 2008. alcoholic drink in 2008.

Above age11 79% of men and Above age11 79% of men and 53% of women drink alcohol.53% of women drink alcohol.

Binge drinking occurs in 12.1% Binge drinking occurs in 12.1% of men and 2.8% of women and of men and 2.8% of women and in 16% of youngsters (18-24)in 16% of youngsters (18-24)

(ISTAT 2008-2010 surveys)(ISTAT 2008-2010 surveys)

Alcohol in Italy: regulations (3)

Forbidden to serve alcohol below age 15Forbidden to serve alcohol below age 15 Allowed to sell alcohol to anyoneAllowed to sell alcohol to anyone Forbidden to serve alcohol in disco bars Forbidden to serve alcohol in disco bars

after 2 amafter 2 am Allowed to sell beer in a bar in front of Allowed to sell beer in a bar in front of

the discothe disco

A little wine protects

373 men born between 1900 and 1920 373 men born between 1900 and 1920 enrolled in the Zutphen Study assessed enrolled in the Zutphen Study assessed repeatedly between 1960 and 2000repeatedly between 1960 and 2000

Drinking up to half a glass of wine daily Drinking up to half a glass of wine daily may increase longevity by 5 years in may increase longevity by 5 years in men, but more studies are neededmen, but more studies are needed

J Epidemiol Community Health. Published online April 30, 2009

Decreased events by light alcohol consumption

Bread consumers in the world In Italy bread In Italy bread

consumption increased consumption increased from 43 Kg in 2001 to 55 from 43 Kg in 2001 to 55 kg in 2006 (200 g per kg in 2006 (200 g per person per day) person per day)

In 2005 out of 22,876,000 In 2005 out of 22,876,000 Italian families, Italian families, 12,870,000 buy fresh 12,870,000 buy fresh bread daily and 844.000 bread daily and 844.000 make bread at home. make bread at home. (ISTAT survey)(ISTAT survey)

There is a recent trend in There is a recent trend in decreasing bread decreasing bread consumptionconsumption

0 50 100

GermanyIreland

ItalyUK

USAFrance

UkraineCanada

Pasta and bread

High consumption of pasta and High consumption of pasta and bread: (Italy: 28 Kg pasta and 122 Kg bread: (Italy: 28 Kg pasta and 122 Kg total grains derivatives/person/year total grains derivatives/person/year Vs. 89 kg average in EU) Vs. 89 kg average in EU)

179179

167167

8989

159159

207207

3232

17173636

41 potato41 potato

2626

Italian consumption per year in pounds

Recent consumption changes in Italy (from 2009 to 2010)

Beef -4.6%Beef -4.6% Wine -3.4%Wine -3.4% Fish -2.9%Fish -2.9% Olive oil +3,7% Olive oil +3,7% Cereals +0.6% (but decr. bread & pasta )Cereals +0.6% (but decr. bread & pasta ) Pork +0.6%Pork +0.6%

Italians drifting away from mediterranean foods 6,500 individuals surveyed in 2007-20086,500 individuals surveyed in 2007-2008

MAI index = calories from MAI index = calories from mediterranean foods/calories from non mediterranean foods/calories from non –mediterraneans foods–mediterraneans foods

Only <20% of individuals MAI >2Only <20% of individuals MAI >2 Worse categories:Worse categories:

Children, teenagersChildren, teenagers Northwest, SouthNorthwest, South

Osservatorio Grana Padano 2008

Pasta dish: nutritionally balancedPasta dish: nutritionally balancedproteins 11 g fat 10 g carbs 57 g

Pasta 70 gPasta 70 g Proteins 7.7 gProteins 7.7 g Fat 0.7 g Carbs 52.5 gFat 0.7 g Carbs 52.5 g

Tomato sauce 60 gTomato sauce 60 g Proteins 1.8 g Carbs Proteins 1.8 g Carbs

2.1 g2.1 g Cheese 5 gCheese 5 g

Prot 1.8 g Fat 01.4 gProt 1.8 g Fat 01.4 g Carbs 2.5 gCarbs 2.5 g

Butter 10 gButter 10 g Fat 8 gFat 8 g

Pasta is cheap in Italy!

Cost of a pasta Cost of a pasta serving in serving in Euros in 2007Euros in 2007

(pasta, tomato, (pasta, tomato, parmesan, parmesan, olive oil, onion)olive oil, onion)

Food consumption in Italy: pasta

ItalyItaly

VenezuelaVenezuelaGreeceGreece USAUSA

SwedenSweden

0

5

10

15

20

25

30

Data 2007

Pasta: how and when?

In a low calorie diet:In a low calorie diet: 70-80 g with simple tomato sauce70-80 g with simple tomato sauce

In a hypercaloric dietIn a hypercaloric diet 120-140 g with ragu sauce or 120-140 g with ragu sauce or

cheese saucecheese sauce As side dish to complement a As side dish to complement a

protein-rich meal (meat or cheese) protein-rich meal (meat or cheese) As a complete meal with some rich As a complete meal with some rich

sauce (seafood and tomatoes…)sauce (seafood and tomatoes…) As fast foodAs fast food

Often found in Italian bars at Often found in Italian bars at lunch timelunch time

Pizza: nutritional facts

330 g330 g caloriescalories proteinsproteins carbscarbs fatsfats

Bianca Bianca (white)(white)

960960 2626 190190 2020

Rossa Rossa (marinara)(marinara)

820820 2323 136136 2121

MargheritaMargherita 930930 1818 175175 1818

CapricciosaCapricciosa 980980 5252 170170 2525

Carbs now: justifiable changes

The observed decrease in consumption of The observed decrease in consumption of bread and legumesbread and legumes and increase in and increase in consumption of meat may be justified in consumption of meat may be justified in terms of adequate aminoacid intake and terms of adequate aminoacid intake and decreased need of total caloriesdecreased need of total calories

Our diet now: unhealthy changes Seed oils (polyunsaturated) instead of olive oilSeed oils (polyunsaturated) instead of olive oil Sweets, cakesSweets, cakes, high caloric density foods, high caloric density foods Sweetened beveragesSweetened beverages Superalcoholic beverages instead of wineSuperalcoholic beverages instead of wine Sausages and cheese instead of fresh foodSausages and cheese instead of fresh food

Carbs, GI and obesity

The notion that high-GI foods lead to The notion that high-GI foods lead to obesity is questionable.. obesity is questionable..

Many populations that eat a large Many populations that eat a large quantity of high-GI foods, such as quantity of high-GI foods, such as Southeast Asians, have significantly Southeast Asians, have significantly lower body weight than populations who lower body weight than populations who consume a lower quantity of these consume a lower quantity of these carbohydrates.carbohydrates.

Carbs are not related to obesity

Fiber rich carb rich foods have a high Fiber rich carb rich foods have a high satiating powersatiating power

For the same weight, carbs have less than For the same weight, carbs have less than half of the calories of fats (4 vs 9)half of the calories of fats (4 vs 9)

Converting carbs to fats burns more Converting carbs to fats burns more calories than converting alimentary fats calories than converting alimentary fats to fat depositsto fat deposits

The mediterranean diet protects against obesity EPIC – PANACEA PROJECTEPIC – PANACEA PROJECT Epidemiological study in Europe on Epidemiological study in Europe on

relations between nutrition/cancer and relations between nutrition/cancer and lifestyle/obesitylifestyle/obesity

367,000 individuals followed for 5 ± 2 367,000 individuals followed for 5 ± 2 yearsyears

EPIC - PANACEA

Traditional mediterranean diet: includes Traditional mediterranean diet: includes olive oilolive oil

Adapted mediterranean diet: includes Adapted mediterranean diet: includes vegetable oilsvegetable oils

Questionnaires on 9 diet components Questionnaires on 9 diet components with a scoring system to assess adherence with a scoring system to assess adherence to the mediterranean modelto the mediterranean model

EPIC - PANACEA

Both traditional and adapted Both traditional and adapted mediterranean diets are protective mediterranean diets are protective against weight gainagainst weight gain

More benefit in youngest individualsMore benefit in youngest individuals More benefit in Southern Europe More benefit in Southern Europe

(Greece, Italy and Spain)(Greece, Italy and Spain)

Mediterranean diet: tradition and healthMediterranean diet: tradition and health Carbohydrates: the winners in ItalyCarbohydrates: the winners in Italy

Obesity: an ongoing battleObesity: an ongoing battle Obesity: the Italian weaponsObesity: the Italian weapons

Obesity in Italy

Health in Italy: obesityItaly Vs. fattest nations in the world Italy Vs. fattest nations in the world

0

20

40

60

80

100

% overweight 44 68 69 74 90

Italy Greece Egypt USATonga, Samoa

2007 estimates

Obesity in Europe 2007

EU adults smoke and obesity 2009

Obesity: latest data and trends

In Italy obesity and overweight have In Italy obesity and overweight have increased with a tendency to stabilize since increased with a tendency to stabilize since 2005 (ISTAT data)2005 (ISTAT data) overweight prevalence about 35%overweight prevalence about 35% obesity prevalence about 10%obesity prevalence about 10% obesity prevalence projected in 2025 14% obesity prevalence projected in 2025 14%

((Società Italiana dell’Obesità (SIO) data)Società Italiana dell’Obesità (SIO) data)

These figures are much less dramatic These figures are much less dramatic than in USA. In 2005 60.5% than in USA. In 2005 60.5% of of American adults were overweightAmerican adults were overweight, , 23.9% obese, and 23.9% obese, and 3.0% morbidly obese3.0% morbidly obese. .

Obesity prevalence in adults 2009

Obesity prevalence in adults 2009

Energy need in Italy 1961-2001

Obesity in Italy: children

In 2000: In 2000: 25% of children obese or overweight25% of children obese or overweight

2009 survey on 8-year old children (Okkio 2009 survey on 8-year old children (Okkio salute): salute): 11.1% obese11.1% obese 22.9% overweight22.9% overweight Geography: combined prevalence Geography: combined prevalence

in Campania 49% in Campania 49% in Valle d’Aosta 23%in Valle d’Aosta 23%

Obesity in Italy: children

Obesity in Italy: children Italian vs. Danish children age 3-6 yearsItalian vs. Danish children age 3-6 years In kindergarten 20% of Italian children are In kindergarten 20% of Italian children are

overweight or obeseoverweight or obese Lower vegetables consumption (27,5% raw, 40% Lower vegetables consumption (27,5% raw, 40%

cooked) vs. 65%cooked) vs. 65% 50% never play outside (vs. 1%)50% never play outside (vs. 1%) Only 20% practice sports (vs. 50%) Only 20% practice sports (vs. 50%) 13.2% watch TV for > 2 hours (vs.3%) 13.2% watch TV for > 2 hours (vs.3%) on weekends 25% vs. 22.7% on weekends 25% vs. 22.7%

Periscope (Pilot European regional interventions for smart childhood obesity prevention in early age) 2009

Obesity and Diabetes in children

ITALY USA

IGT 11% 23%

IFG 1%

DMT2 0.5% 2.5%

Metabolic syndrome

22% 45%

Bambin Gesu Hospital, Rome 2007

Sedentary lifestyle in Europe

Obesity and cycling in Europe

Sedentary lifestyle in Italy

Only 20% regularly practice sportsOnly 20% regularly practice sports 60-65% of the Italian population is sedentary - 60-65% of the Italian population is sedentary -

no sports or less than one hour a weekno sports or less than one hour a week Progressive decrease of sports activity with ageProgressive decrease of sports activity with age 50% of Italians practice sports till age 14, 35% 50% of Italians practice sports till age 14, 35%

at 20-24, 25% at 25-34 yearsat 20-24, 25% at 25-34 years

Italian TV and obesity

In early afternoon, soap opera time for In early afternoon, soap opera time for housewives, there are more commercials on housewives, there are more commercials on

sweet drinks, snacks, cheeses and sweet drinks, snacks, cheeses and merendinemerendine

AND AND slimming and diet productsslimming and diet products

(SIAN survey 2001, Collegno)(SIAN survey 2001, Collegno)

Food advertising in Italian TV

0

10

20

30

40

50

60

70

80

90

USA UK Italy

food adsjunk food

Food ads as % of ads; junk as % of food

Caroli 2001

Obesity in Italy - dieting

Source: Istututo Auxologico Survey 1999

overweight obese generalpopulation

prevalence

13

18

11

02468

1012141618

Methods to loose weight in Italy

D’Amicis, Physical Activity Survey 1998

0 20 40 60 80

Diet

gym

diet & gym

drugs

other

nothing

womenmen

What Italians do about obesity?

Nothing: 30%Nothing: 30% Self-dieting: 14%Self-dieting: 14% Consult nutritionist or physician at least Consult nutritionist or physician at least

once: 56%once: 56% 60% don’t know the Mediterranean diet 60% don’t know the Mediterranean diet

characteristicscharacteristics

2009 ISTAT survey

Obesity day

Every year since 2001Every year since 2001 More than 150 centers More than 150 centers

nationwidenationwide Practical info on obesity Practical info on obesity

to the general publicto the general public Promotion of obesity Promotion of obesity

clinics in public hospitalsclinics in public hospitals

Mediterranean diet: tradition and healthMediterranean diet: tradition and health Carbohydrates: the winners in ItalyCarbohydrates: the winners in Italy Obesity: an ongoing battleObesity: an ongoing battle

Obesity: the Italian weaponsObesity: the Italian weapons

Diet therapy in Italy

Diet therapy debate in Italy

biologists can only suggest dietary biologists can only suggest dietary guidelines to improve health but cannot guidelines to improve health but cannot prescribe a therapeutic diet which should prescribe a therapeutic diet which should exclusively given by physicians (Italian exclusively given by physicians (Italian Supreme Court 2011)Supreme Court 2011)

History of popular diets

Dissociated (Hay Dissociated (Hay 1930)1930)

Very popular in Italy - separation between Very popular in Italy - separation between proteins and carbohydratesproteins and carbohydrates

Weight Watchers Weight Watchers (J. Nidetch 1960)(J. Nidetch 1960)

In Italy since 1973. Italian version: Dieta In Italy since 1973. Italian version: Dieta punti (Razzoli) very popular in the pastpunti (Razzoli) very popular in the past

Atkins (1972) Atkins (1972) Scarsdale Scarsdale

In Italy brief popularity of version based on In Italy brief popularity of version based on high protein bread (pane di Rivalta) high protein bread (pane di Rivalta)

Pritikin (1975)Pritikin (1975)

Ornish (1990)Ornish (1990)

Recently popular in the hard version Recently popular in the hard version (minestrone)(minestrone)

Beverly Hills Beverly Hills (Mazel, 1980)(Mazel, 1980)

manymany

Herbalife (1980)Herbalife (1980) Italian version - multilevel marketing Italian version - multilevel marketing

History of popular diets

Mediterranean Mediterranean (1990)(1990)

Often prescribed by nutritionistsOften prescribed by nutritionists

Montignac Montignac Italian version – low Glycemic index dietItalian version – low Glycemic index diet

Zona (Sears, 1995)Zona (Sears, 1995) Italian versionsItalian versions

DukanDukan Italian version now popular – low fat, very Italian version now popular – low fat, very high proteins – no scientific data, “one of high proteins – no scientific data, “one of the worst diets in 2011 (Brit Diet Assoc)the worst diets in 2011 (Brit Diet Assoc)

Zone diet vs. Mediterranean Diet Barry Sears vs Eugenio Del Toma

Eugenio Del Toma:Eugenio Del Toma: rules are complicated and difficult to follow rules are complicated and difficult to follow

on a long term period on a long term period In human nutrition, psychological aspects are In human nutrition, psychological aspects are

essentialsessentials We prefer tastes, smells and situations We prefer tastes, smells and situations

associated with past happy memoriesassociated with past happy memories The best prevention of obesity is to eat without The best prevention of obesity is to eat without

disrupting our emotionsdisrupting our emotions

Zone diet vs. Mediterranean Diet

Typical Mediterranean dietTypical Mediterranean diet Proteins 15% fats 25% carbs Proteins 15% fats 25% carbs

60%60% Corrected Mediterranen dietCorrected Mediterranen diet

Proteins 20% fats 25% carbs Proteins 20% fats 25% carbs 55%55%

Proteins = Proteins = white meats, fish, white meats, fish, legumes, fresh cheeseslegumes, fresh cheeses

fats = fats = olive oilolive oil carbs = carbs = fruits and vegetables, fruits and vegetables,

bread, pasta, ricebread, pasta, rice

Zone diet vs. Mediterranean Diet

Typical Zone dietTypical Zone diet Proteins 30% fats 30% carbs 40%Proteins 30% fats 30% carbs 40% Carbs: relatively more fruits and Carbs: relatively more fruits and vegetables, much less starches, barley, oat vegetables, much less starches, barley, oat Fats: olive oil, more Omega-3Fats: olive oil, more Omega-3

““When compared to all of the popular diets, the When compared to all of the popular diets, the Mediterranean diet is the most similar to the Zone in terms of Mediterranean diet is the most similar to the Zone in terms of balance and moderation coupled with common sense.You balance and moderation coupled with common sense.You should consider the Mediterranean diet as a less sophisticated should consider the Mediterranean diet as a less sophisticated version of the Zone. “ version of the Zone. “

(from www.drsears.com(from www.drsears.com))

Medit vs Zone vs Low-fat diets

Mediterranean diet and diabetes

Newly diagnosed diabetics who were overweight Newly diagnosed diabetics who were overweight better managed their disease by eating a better managed their disease by eating a Mediterranean diet rich in fish, fruits and Mediterranean diet rich in fish, fruits and vegetables instead of one low in fat (AHA diet)vegetables instead of one low in fat (AHA diet)

>200 patients followed for 4 years>200 patients followed for 4 years BMI – 1.2 vs 0.9BMI – 1.2 vs 0.9 Risk of need for medications decreased by 32%Risk of need for medications decreased by 32%

Annals Int Med Sept 2009

Lemme Diet

Recent popular commercial dietRecent popular commercial diet Combination of dissociated low carb Combination of dissociated low carb

dietsdiets Exclusions: salt, sugar, sweeteners, Exclusions: salt, sugar, sweeteners,

bread, milk, dairybread, milk, dairy Meat and pasta cannot be combinedMeat and pasta cannot be combined

Lemme Diet: typical week

BF: turkey and coffeeL: beef and coffeeBF: turkey and coffeeL: beef and coffeeD: swordfish and coffeeD: swordfish and coffee

BF: pasta oil redpepper and coffeeL: BF: pasta oil redpepper and coffeeL: chicken breast and coffeeD: sole and chicken breast and coffeeD: sole and coffeecoffee

BF: artichokes and coffeeL: beef and BF: artichokes and coffeeL: beef and coffeeD: fish and coffeecoffeeD: fish and coffee

The last craze: the TISANOREICA Another variation Another variation

of ketogenic dietof ketogenic diet Package with Package with

protein protein supplements and supplements and herbal extractsherbal extracts

www.gianlucamech.itwww.gianlucamech.it

The last craze: the TISANOREICA diet Very aggressive promotional tacticsVery aggressive promotional tactics TV shows, Italian Parliament, TV shows, Italian Parliament,

international meetingsinternational meetings

The last craze: the TISANOREICA diet Followed by VIP: BerlusconiFollowed by VIP: Berlusconi

The last craze: the TISANOREICA diet Followed by VIP: WittstockFollowed by VIP: Wittstock

Dimagenina

Intragastric Bulking Intragastric Bulking Agent – non-Agent – non-prescriptionprescription

2-3 capsules before 2-3 capsules before meals with watermeals with water

Rapid volume increaseRapid volume increase Degradation in 1 hourDegradation in 1 hour Often cramps and painOften cramps and pain

Enteral chetogenic nutrition “NEC”

Very recent and commercially Very recent and commercially successful modality offered in a some successful modality offered in a some Italian centersItalian centers

Nasogastric tube feeding of proteins Nasogastric tube feeding of proteins and electrolytes (<300 cal/day)and electrolytes (<300 cal/day)

2 mm NG tube connected to a pump2 mm NG tube connected to a pump 2 L of water mixed with a aminoacid 2 L of water mixed with a aminoacid

concentrate 35-40 g at 85 ml/hrconcentrate 35-40 g at 85 ml/hr

Enteral chetogenic nutrition “NEC”

In addition to enteral In addition to enteral feeding:feeding: Proton pump Proton pump

inhibitorsinhibitors LaxativesLaxatives VitaminsVitamins mineralsminerals

NEC protocol

Cycles of 10 days with Cycles of 10 days with 3-week intervals3-week intervals

Claimed weight lossClaimed weight loss 9-13% in the first 9-13% in the first

cyclecycle 7- 10% in the 7- 10% in the

second cyclesecond cycle

Position statement 2011

•NEC is not a treatment for obesity•It is different from PSMF and EN•Should be called “fasting with low protein intake”•There are no EBM data and no publications•Effectiveness, role and risk are still to be defined

Bariatric surgery in Italy

Bariatric procedures

Bariatric surgery vs diet: SOS 2010

Number of bariatric procedures : 18,363Number of bariatric procedures : 18,363Number of centers: 122Number of centers: 122

SICOB Registry – June 2011

SICOB Registry – 2011types of procedures

SICOB Registry – 2011mortality

Purely restrictivePurely restrictive Endoscopic placement and Endoscopic placement and

removal with sedationremoval with sedation Temporary measure limited Temporary measure limited

to six monthsto six months Not yet FDA-approved in Not yet FDA-approved in

USAUSA

500-600 ml saline

with methylene blue

Intragastric balloonIntragastric balloon

To collect italian experience on BIB

18 centers 18 centers

patients n. 3824patients n. 3824(may 2000 – july 2007)

G.I.L.B

30

35

40

45

0 1 2 3 4 5 6

RESULTS RESULTS ( n = 3824)( n = 3824)

6 months BMI: 36.96 months BMI: 36.96.4 (range:6.4 (range:27-50 Kg/m27-50 Kg/m22 ) )BMI

Months

44.244.2

36.936.9

- 7.3- 7.3

Italian experienceItalian experience(G.I.L.B)(G.I.L.B)

Gastric occlusion: 5 (0.24%)

BIB early rupture: 9 (0.4%)

*Esophagitis: (EGDS diagnosis): 3 (0.15%)

Gastric ulcer: 1 (0.04%)

Gastric acute dilation 2 (0.1%)

POST-PLACEMENT

22/ 2009 (1.1%)

COMPLICATIONS:

(weight loss < 10 % of initial weight)

FAILURES = 12.4%FAILURES = 12.4%

(sweet eaters, bulimic, grazing pts.)

Italian experienceItalian experience(G.I.L.B)(G.I.L.B)

GILBGILB

MAJOR COMPLICATIONSMAJOR COMPLICATIONS

Gastric Occlusion Gastric Occlusion 19 (0.49%)(0.49%)

Gastric PerforationGastric Perforation 5 (0.13%) **

Gastric UlcerGastric Ulcer 10 (0.26%)

Bowel Occlusion Bowel Occlusion 3 (0.07%)

3737 / 3824 (0.96%) / 3824 (0.96%)

(Prior Gynecological surgery)(Prior Gynecological surgery)

M/F 301/652Age 37.5 (19-69) yearsBMI 41.2 (30.7-56.5) kg/m2

%EW 61.3 % (34-117.6)

March 1998 – June 2009

1,010 placements

BIB - Policlinico Umberto IDr. Genco’s series

FemaleAge < 35 years

BMI < 40

Predictive Factors

P < 0.05

EWL%:EWL%: ns ns At removalAt removal

Results

LONG TERM FOLLOW-UP (5 YEARS)LONG TERM FOLLOW-UP (5 YEARS) AFTER BIB TREATMENT IN OBESE PATIENTSAFTER BIB TREATMENT IN OBESE PATIENTS

98%98%

51 %51 %

75 %75 %

% PtsPost-placement symptoms

65 %65 %

(1-2 days)

(1 day)

(1-2 days)

(2-3 days)

Genco series March 1998 – March 2007 700 BIB placements

Imaz I et al meta-analysis Obes Surg 18:841, 2008

1.8%

0.9%

0.6%

0.3%

0.2%

0.2%

0.1%

0.1%

0.1%

Imaz I et al meta-analysis Obes Surg 18:841, 2008

2 patients

parameter N of patients result

Weight loss vs placebo BMI

39 – 3.2

Weight loss vs placebo Kg

39 - 6.7

Weight loss BMI 3,200 - 5.7

Weight loss Kg 3,608 - 14.7

IGB – Efficacy/effectiveness at 6 months

Imaz I et al meta-analysis Obes Surg 18:841, 2008

Meta-analysis conclusionsMeta-analysis conclusions

• Weight loss 14.7 Kg, less than 30-40 Kg of bariatric surgery

• Weight loss 12.2% of initial weight, more than 10% considered beneficial for comorbidities

• Efficacy (vs placebo) – 6.7 Kg, better than sibutramine (4.4 kg) and orlistat (2.9 Kg)

• Low rate of complications

• Weight loss 14.7 Kg, less than 30-40 Kg of bariatric surgery

• Weight loss 12.2% of initial weight, more than 10% considered beneficial for comorbidities

• Efficacy (vs placebo) – 6.7 Kg, better than sibutramine (4.4 kg) and orlistat (2.9 Kg)

• Low rate of complications

Imaz I et al meta-analysis Obes Surg 18:841, 2008

Evidence based review of BIB for weight loss

Evidence based review of BIB for weight loss

• Safe in selected patients• Effective in two thirds of the

patients• Mean Weight loss 17.8 Kg• Improvement of comorbidities • No data of predictive factors and

long term results

• Safe in selected patients• Effective in two thirds of the

patients• Mean Weight loss 17.8 Kg• Improvement of comorbidities • No data of predictive factors and

long term results

Dumonceau EBM review Obes Surg 18:1611, 2008

2-year weight loss: BIB vs diet2-year weight loss: BIB vs diet

Genco A et al Obesity Surgery 2008

30

32

34

36

38

40

42

44

0 6 12

Group A (BIB+Diet)Group B (BIB+BIB)

Sequential BIB insertion

BIB placement

months

BMI

BIB removal

p = 0,04

BMI

BIBBIB

DIETDIET

ten commandaments

on obesity

ten commandaments

on obesity follow a balanced and varied diet; have an active lifestyle avoid "do-it-yourself" diets alternating restrictions and binges may cause weight gain do not follow friends' diets, they may not be appropriate for

you remember: often mass-media promotes diets have no

scientific value do not fast or follow excessivey restrictive diets with

exclusion of entire classes of nutrients assess your health conditions before starting a diet ask your physician or nutritionist before taking supplements invasive weight-loss therapies should be prescribed only by

physicians bariatric surgery should be performed only in morbidly

obese individuals and requires long-term clinical and nutritional followups

follow a balanced and varied diet; have an active lifestyle avoid "do-it-yourself" diets alternating restrictions and binges may cause weight gain do not follow friends' diets, they may not be appropriate for

you remember: often mass-media promotes diets have no

scientific value do not fast or follow excessivey restrictive diets with

exclusion of entire classes of nutrients assess your health conditions before starting a diet ask your physician or nutritionist before taking supplements invasive weight-loss therapies should be prescribed only by

physicians bariatric surgery should be performed only in morbidly

obese individuals and requires long-term clinical and nutritional followups

All the world loves Italy because it is old but still glamorous. Because it eats and drinks well but is rarely fat or drunk. Ian Fisher an Fisher in thein the New New

York Times,York Times, December December 13, 200713, 2007