“Obesity - from Clinical Practice to Research” Donal O’Shea October 12Th 2013 IPNA, Athlone

“Obesity - from clinical practice to research” Donal O’Shea October 12th 2013 IPNA, Athlone. Outline of talk

• A bit of background

• Why we are where we are

• A healthy lifestyle

• Some of our research Obesity: like no previous epidemic • Diabetes • Cancer • Dementia • Cardiovascular Disease • Asthma • Arthritis

Causes 4000 – 6000 Deaths per year in Ireland (Pop 5 million)

Suicide deaths 486 (2011), Road deaths 161 (2012) Percentage increase in BMI categories since 1986

Sturm and Hattori, Int J Obes 2012 Body Mass Index 40 & 50

BMI 40 BMI 52 Body Mass Index 40 & 50

BMI 40 BMI 52 Guess 32 Guess 41 General facts

• Average woman (5 ft 4) normal weight up to 10 stone (65 kilos) needs 1700-1800 kcal per day up tp 50yo then 1500kcal per day

• Average man (5ft 10) normal weight up to12 stone (78 kilos) needs 1900-2000 kcal per day up to 50yo then 1700 kcal

General Facts

• From age of 4 to 14 child should be half age in stone General Facts

• From age of 4 to 14 child should be half age in stone (depends on height)

4 year old – 2 stone 8 year old – 4 stone 14 year old – 7 stone

And then they fill out….. Childhood Obesity in Ireland (and Europe)

• 25% 3 year olds overweight/obese • 25% 9 years olds overweight/obese

• low self image, concept and self esteem

Growing up in Ireland 2009

Median BMI for each 5-year rise in age of onset of overweight

O’Connell et al JPHN 2011 Young Scientist 2012 Age v Weight 75

40 Weight(kg) 35

15 4 4.5 5 5.5 6 6.5 7 7.5 8 8.5 9 9.5 10 10.5 11 11.5 12 12.5 13 13.5 14 Age

• Study cohort - 6328 subjects (2961 male) – mean age 11.4 ± 4.0 years at baseline – mean length of follow-up 23.1 ± 3.3 years

• 5554 subjects normal weight as children – 812 (15%) were obese as adults

• 774 subjects overweight or obese as children – 500 (65%) were obese as adults

• 147 subjects obese as children – 121 (82%) were obese as adults

Juonala et al, NEJM 2011 This Becomes this

BMI 51 BMI 52 Becomes this (82% chance)

BMI 51 BMI 52 1km Walk: BMI Normal Range

1km walk time: 7 mins – 11 mins: 6-8km/hr Estimated calorific expenditure: 45-74 Calories

BMI: 25kg/m2

www.caloriesperhour.com 1km Walk: BMI 25 - 35kg/m2

BMI: 32Kg/m2 1km walk time: 10 Mins – 16 Mins Estimated calorific expenditure: 56-82 Calories

2x 1km Walk: 35 – 45kg/m2

1km Walk Time: BMI: 40kg/m2 13 Mins - 15 Mins Estimated calorific expenditure: 84 – 90 Calories 1km Walk: BMI 45 – 55kg/m2 BMI: 44kg/m2 1km Walk Time: 13Mins – 18Mins Estimated calorific expenditure: 2 BMI: 51kg/m 97 – 150 Calories 1km Walk: 55 – 75 Kg/m2 BMI: 64kg/m2 1km Walk Time: 13Mins – 19Mins Estimated calorific expenditure: BMI: 76 Kg/m2 131 – 164 Calories Outline of talk

• A bit of background

• Why we are where we are

• A healthy lifestyle

• Some of our research

TOXIC ENVIRONMENT

They tell you what they do.. Nutrition in pregnancy vital Albert Einstein (1879 - 1955)

I fear the day when the technology overlaps with our humanity.

Albert Einstein (1879 - 1955)

I fear the day when the technology overlaps with our humanity. The world will only have a generation of idiots.

Times and play have changed…. Sedentary Time

Now 4th leading preventable cause of death

“Lack of activity destroys the good condition of every human being, while movement and methodical physical exercise save it and preserve it.”

Sedentary Time

Now 4th leading preventable cause of death

“Lack of activity destroys the good condition of every human being, while movement and methodical physical exercise save it and preserve it.” - Plato

American Diabetes Association Consumption of free sugar has soared Consumption of sweet beverages and type 2 diabetes incidence in European adults: results from EPIC-InterAct.

Diabetologia. 2013 Apr 26th

“This study corroberates the evidence between incidence of type 2 diabetes and high consumption of sugar sweetened drinks”

GSK decision to sell Ribena and Lucozade. Sports Drinks

• Growing Up Today Study II • Large Prospective Study • 5995 girls/4906 boys • 9-16 years old • Consumption of sports drinks strongly associated with weight gain (Field et al, Consumption of Sports Drinks Prospectively Associated with Greater Weight Gain among Adolescents, Obesity Society Meeting 2012) Dental Effects • Enamel starts to dissolve when the pH falls below 5.5

Atrill: Financial Management for Non- Specialists 3rd edition © Pearson Education OHT 9.39 Ltd. 2003 120z Drink Tsp Sugar PH

WATER 0 7

SPRITE 10 3.3

MOUNTAIN DEW 12 3.3

DIET PEPSI 0 3.0

PROPEL FITNESS 1 3.4 WATER Atrill: Financial Management for Non- Specialists 3rd edition © Pearson Education OHT 9.40 Ltd. 2003 Bottle Caries

Atrill: Financial Management for Non- Specialists 3rd edition © Pearson Education OHT 9.41 Ltd. 2003

Calories while running or swimming • Lucozade Sport 140 Calories • Lucozade Energy 350 Calories • Powerade 80 Calories • Hydrate BPM 317 Calories • Mace Glucose 332 Calories

It takes 2 hours of exercise to burn off a can of coke and packet of crisps!!! Currently Irish 5-12 year olds get • 20% of their calories from sweets, snacks and buscuits

• Get an average of 63 caloires per day from fizzy/soft drinks (23,000 calories/year)

Outline of talk

• A bit of background

• Why we are where we are

• A healthy lifestyle

• Some of our research

A healthy diet

• 60% Carbohydrate

• 15% Protein

• 25% Fat The New Food Guide is based on... Whats important?

• Overall balanced diet

• Adequate carbohydrate, protein & fat

• Adequate Fluids

• Regular eating pattern Needs of Children, Teenagers and Adults

5 – 13 year olds 14 – 18 year olds

19 – 50 year olds 51+ year olds A Balanced diet

• A varied colourful diet cotains all the essential nutrients that you need ie Carbohydrate (sugars) Protein Fat Fibre Vitamins & minerals Water

Practical advice booklet Work off the pyramid

Cereals, Breads, Potatoes, Pasta & Rice Group • What is a serving size? • Calorie range of different foods • How many servings are needed? • How to advise on weight loss

200ml disposable plastic cup Fruit, Vegetables and Salads Group • What is a serving size? • MORE is BETTER • How many servings are needed?

200ml disposable plastic cup Simple Rule for Healthy Eating

Base your meals on Cereals, Breads, Potatoes, Pasta and Rice, with plenty of Fruit, Vegetables and Salads Milk, Yoghurt & Cheese Group

• What is a serving size? • Low-fat is best - Milk and • Yoghurt more than Cheese • How many servings are needed?

200ml Matchbox disposable size piece plastic cup of cheese Meat, Poultry, Fish, & Alternatives Group • Measuring a serving

size D

• Main meal • Light meal

Palm of the hand • Other Foods

NOT too MUCH and NOT too OFTEN Jams/Honey/Sugar vs. Other Sugary Foods

Using the food guide for advice Using the food guide for advice

Fold over kids page Or the 19-50’s page Using the food guide for advice

Or the last chance saloon page (51+) What about physical activity?

Does type of exercise matter?

• Resistance – burns calories and builds muscle and encourages weight gain Does type of exercise matter?

• Endurance - burns calories and is optimum for weight management How much? (EVERY DAY)

• At least 1 hour moderate to vigorous

• Mix of resistance and endurance Physical Activity Pyramid

Outline of talk

• A bit of background

• Why we are where we are

• A healthy lifestyle

• Some of our research

Obesity causes and worsens outcome in…… • Diabetes • Cancer • Dementia • Sleep Apnoea • Asthma • Everything

• Suggests a common mechanistic fault • Focussed our research on the immune system Studied 4 cell types in detail to date

• Natural Killer cells

• Invariant Natural Killer T cells

• Dendritic cells

• Macrophages

• All cell type characterised by different cell surface markers

Flow cytometry

CD3

6B11 Various cell types – with different

markers

CD3

6B11 Flow cytometry Flow cytometry Various cell types – with different

markers

CD3

6B11 Natural Killer Cell - the foot soldier of the immune system

• Key cell in attacking viruses and cancer cells

• Involved in a range of autoimmune conditions

n 110,= 0.006= p NK cells (% total lymphocytes) 12.5 17.5 22.5 27.5 2.5 7.5 10 15 20 25 0 5

natural killer cells in obesity Decrease in circulating obese

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Represents 0.2% - 1.2% of circulating T cells Cytotoxicity DCs

Interacts with other immune cells to determine the Chemokines B cells downstream immune response: Macrophages Pro-inflammatory Anti-inflammatory Cytotoxic

iNKT cells are reduced in human obesity

***

Lean Obese 0.90

0.75

0.60

0.45

0.30

iNKT T (% cells)iNKT 0.15

0.0 NKT cells (% cells) T (% cells NKT Obese Lean

Could this explain the complications of obesity? Did a study in Boston. Immune deficient mice get much fatter and diabetic – and its reversible. WT on HFD Ja18KO on HFD

*** 40 ***

*** * 35 ** ** ** 30 * **

Weight (g) Weight 25 Weight (g) Weight 20 0 1 2 3 4 5 6 7 8 9 Lean Mass: 12.3g Lean Mass: 12.3g Weeks Fat Mass: 8.9g Fat Mass: 20g % Fat: 42% % Fat: 61.9% Fat pads Fat pads 3 *

20 12

10 2 15 ** * 8 10 6

1 Weight (g) Weight

Gain (g) Gain 4 5 2 WT (g) mass Lean 0 Ja18KO SFD WT Ja18KO 0 0 WT Ja18KO WT Ja18KO

Conclusion

• Weight regulates the immune system

• Immune sytem regulates weight

• Explains why weight loss is so difficult Primal defence system in place

• In 2012 moved our focus to childrens immune system Childrens Baseline Data

Lean Obese Age 12.6 yrs old 11.9 yrs old Number 20 30 Weight 52kgs 90kgs Glucose 4.9 5.1 Insulin Childrens Baseline Data

Lean Obese Age 12.6 yrs old 11.9 yrs old Number 20 30 Weight 52kgs 90kgs Glucose 4.9 5.1 Insulin 21 149 Reduction in iNKT cells number and function already present in obese

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m 0 20 30 40 50 -1 BMI Summary in Children

• Innate immune system is switching off

• Genes for type 2 diabetes and heart disease are switched on

• Genes for stopping cancer are switched off The Imperatives for prevention

• There is no way back Defence against weight loss is primal

• Health Burden Crosses all disease Mental, Dental, Physical

• Financial

We have been here before......

Sanitary HIAP Revolution Revolutio

KICKBUSCH DUBLIN 2013 We need a public health revolution

Sanitary HIAP Revolution Revolutio

KICKBUSCH DUBLIN 2013 What we have chosen to forget

• 19th century: • The Poor Law Commission argues in 1838, • Sanitary surveys proved that a relationship exists • “The expenditures between communicable necessary to the disease and filth in the adoption and environment, and it was maintenance of said that safeguarding measures of prevention public health is the would ultimately province of the amount to less than the engineer rather than cost of the disease now of the physician. constantly engendered.”

KICKBUSCH DUBLIN 2013 Summary

Replace sugar sweetened drinks with water

Watch portion size and use the pyramid

Be active for more than an hour every day

Sleep for at least 6 hours up to 8 hours …. the famous statue returns to Italy Questions

Need environment conducive to exercise