Carb obesity and food culture in italy 2012

Vincenzo Bacci, MD,Vincenzo Bacci, MD,
FACEFACE

Our topics for today
 Mediterranean diet: tradition andMediterranean diet: tradition and
healthhealth
 Carbohydrates: the winners inCarbohydrates: the winners in
ItalyItaly
 Obesity: an ongoing battleObesity: an ongoing battle
 Obesity: the Italian weaponsObesity: the Italian weapons

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

MeditMediterraneanerranean DietDiet?? In 1000 BC…In 1000 BC…
 DietDiet - from- from δαιταδαιτα = lifestyle= lifestyle
 Mediterranea - fromMediterranea - from MEDITERRANEVSMEDITERRANEVS = (sea)= (sea)
in the middle of landsin the middle of lands
 lifestyle and nutritional habits
developed over the centuries by the
populations that originated Greek
e Roman civilizations

MediMediterraneanterranean DietDiet :: in 1970…in 1970…
 In the 50’s and 60’s Ancel e Margaret KeysIn the 50’s and 60’s Ancel e Margaret Keys,,
make the first observation on nutrition andmake the first observation on nutrition and
health on the southern Italy and Cretehealth on the southern Italy and Crete
populationspopulations
 ““Seven Countries Study - How to eat wellSeven Countries Study - How to eat well
and stay well - The Mediterranean Diet” isand stay well - The Mediterranean Diet” is
published inpublished in 1977.1977.

Mediterranean region: commonMediterranean region: common
features and differencesfeatures and differences
 In the Mediterranean regionIn the Mediterranean region mortality andmortality and
cardiovascular morbidity are lowercardiovascular morbidity are lower than otherthan other
western regionswestern regions
 In general the eating pattern is balanced and similar toIn general the eating pattern is balanced and similar to
thethe theoretical cardioprotective compositiontheoretical cardioprotective composition
 On the other hand we observe important differences inOn the other hand we observe important differences in
socioeconomic conditions, traditional eating habits andsocioeconomic conditions, traditional eating habits and
recent trends in the different countries of the area.recent trends in the different countries of the area.

MediMediterraneanterranean 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 fatsAbundant animal fats
(butter, cheeses, foi gras),(butter, cheeses, foi gras),
red wine (French paradox )red wine (French paradox )
 Middle East, NorthMiddle 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
81.4
80.3
79.9
79.9
79.8
79.4
78.7
78
72.9
71.6
68.6
65.9
65 70 75 80 85
Japan
Canada
Italy
France
Spain
Greece
UK
USA
China
Egypt
India
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 yearsfemale: 84.5 years
 USAUSA
 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 yearsfemale: 80.9 years
Source: Indexmundi.com

EU Cardiovascular mortality 2004-2008

 Not a dietNot a diet
 Rather, lifestyle with frugal eatingRather, lifestyle with frugal eating
 Mostly disappeared due to theMostly disappeared due to the
internationalization and globalizationinternationalization and globalization
 Many really traditional dishes nowMany really traditional dishes now
emarginatedemarginated
 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 MediterraneanSince 2010 the Mediterranean
diet is included in the UNESCOdiet is included in the UNESCO
list celebrating the world'slist 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 ofit has given rise to a considerable body of
knowledge, songs, maximsknowledge, songs, maxims
 It is rooted in respect for the territory andIt is rooted in respect for the territory and
biodiversitybiodiversity

 Mediterranean diet: tradition and healthMediterranean diet: tradition and health

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, fewFruits :(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 inScarce consumption of potatoes in
Southern ItalySouthern Italy

The Mediterranean Diet Temple: carbohydrates
Sparingly
“bearing” foods
Condiments and wine

Changes in Italy: the last
century
Novecento
Bertolucci 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 calorieswere cheap sources of proteins and calories
with a good aminoacid combinationswith 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 (= breadPane e acqua (= bread
and water) in prisonersand water) in prisoners
 Pane e olio / bruschettaPane e olio / bruschetta
(bread and oil) in(bread and oil) in
peasantspeasants
 Pater noster…PanemPater noster…Panem
nostrum cotidiánum danostrum cotidiánum da
nobis hodie = Ournobis hodie = Our
Father… Give us thisFather… 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 (sedentaryToday low energy expenditure (sedentary
white collar, falsely hyperactive executive, evenwhite collar, falsely hyperactive executive, even
modern agricultural worker) and abundance ofmodern agricultural worker) and abundance of
cheap foodcheap food
 Bread, pasta and legumesBread, pasta and legumes considered a badconsidered a bad
choice in a diet which must have limited caloricchoice in a diet which must have limited caloric
intakeintake
 A portion of steak supplies essential aminoacidsA portion of steak supplies essential aminoacids
with 150 calories as 100 g ofwith 150 calories as 100 g of breadbread (290 cal) or(290 cal) or
beansbeans (280 cal)(280 cal)

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

Italy: The Manzo family of Sicily
Food 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

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 (1)
 18.6% of youngsters age 11-15 drink18.6% of youngsters age 11-15 drink
alcohol regularly, often binge drink onalcohol regularly, often binge drink on
weekendsweekends
 Higher consumption in Emilia andHigher consumption in Emilia and
Veneto; lower in Campania and CalabriaVeneto; lower in Campania and Calabria
 20% of teenagers get intoxicated on20% of teenagers get intoxicated on
weekends (ISTAT survey 2007)weekends (ISTAT survey 2007)

Alcohol in Italy (2)
 19.7% of boys and 15.3% of19.7% of boys and 15.3% of
girls under 15 had at least onegirls under 15 had at least one
alcoholic drink in 2008.alcoholic drink in 2008.
 Above age11 79% of men andAbove age11 79% of men and
53% of women drink alcohol.53% of women drink alcohol.
 Binge drinking occurs inBinge drinking occurs in
12.1% of men and 2.8% of12.1% of men and 2.8% of
women and in 16% ofwomen and in 16% of
youngsters (18-24)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 barsForbidden to serve alcohol in disco bars
after 2 amafter 2 am
 Allowed to sell beer in a bar in front ofAllowed to sell beer in a bar in front of
the discothe disco

A little wine protects
 373 men born between 1900 and 1920373 men born between 1900 and 1920
enrolled in the Zutphen Study assessedenrolled in the Zutphen Study assessed
repeatedly between 1960 and 2000repeatedly between 1960 and 2000
 Drinking up to half a glass of wine dailyDrinking up to half a glass of wine daily
may increase longevity by 5 years inmay 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 breadIn Italy bread
consumption increasedconsumption increased
from 43 Kg in 2001 to 55from 43 Kg in 2001 to 55
kg in 2006 (200 g perkg in 2006 (200 g per
person per day)person per day)
 In 2005 out of 22,876,000In 2005 out of 22,876,000
Italian families,Italian families,
12,870,000 buy fresh12,870,000 buy fresh
bread daily and 844.000bread daily and 844.000
make bread at home.make bread at home.
(ISTAT survey)(ISTAT survey)
 There is a recent trend inThere is a recent trend in
decreasing breaddecreasing bread
consumptionconsumption
0 50 100
Germany
Ireland
Italy
UK
USA
France
Ukraine
Canada

Pasta and bread
 High consumption of pasta andHigh consumption of pasta and
bread: (Italy: 28 Kg pasta andbread: (Italy: 28 Kg pasta and
122 Kg total grains122 Kg total grains
derivatives/person/year Vs. 89 kgderivatives/person/year Vs. 89 kg
average in EU)average in EU)

179179
167167
8989
159159
207207
3232
1717
3636
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 fromMAI index = calories from
mediterranean foods/calories from nonmediterranean 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 balanced
proteins 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 CarbsProteins 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 pastaCost of a pasta
serving inserving in
Euros in 2007Euros in 2007
 (pasta, tomato,(pasta, tomato,
parmesan,parmesan,
olive oil, onion)olive oil, onion)

Food consumption in Italy: pasta
ItalyItaly
VenezuelaVenezuela
GreeceGreece 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 or120-140 g with ragu sauce or
cheese saucecheese sauce
 As side dish to complement aAs side dish to complement a
protein-rich meal (meat or cheese)protein-rich meal (meat or cheese)
 As a complete meal with some richAs a complete meal with some rich
sauce (seafood and tomatoes…)sauce (seafood and tomatoes…)
 As fast foodAs fast food
 Often found in Italian bars atOften found in Italian bars at
lunch timelunch time

Pizza: nutritional facts
330 g330 g caloriescalories proteinsproteins carbscarbs fatsfats
BiancaBianca
(white)(white)
960960 2626 190190 2020
RossaRossa
(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 ofThe observed decrease in consumption of
bread and legumesbread and legumes and increase inand increase in
consumption of meat may be justified inconsumption of meat may be justified in
terms of adequate aminoacid intake andterms 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 toThe notion that high-GI foods lead to
obesity is questionable..obesity is questionable..
 Many populations that eat a largeMany populations that eat a large
quantity of high-GI foods, such asquantity of high-GI foods, such as
Southeast Asians, have significantlySoutheast Asians, have significantly
lower body weight than populations wholower body weight than populations who
consume a lower quantity of theseconsume a lower quantity of these
carbohydrates.carbohydrates.

Carbs are not related to obesity
 Fiber rich carb rich foods have a highFiber rich carb rich foods have a high
satiating powersatiating power
 For the same weight, carbs have less thanFor 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 moreConverting carbs to fats burns more
calories than converting alimentary fatscalories than converting alimentary fats
to fat depositsto fat deposits

The mediterranean diet
protects against obesity
 EPIC – PANACEA PROJECTEPIC – PANACEA PROJECT
 Epidemiological study in Europe onEpidemiological study in Europe on
relations between nutrition/cancer andrelations between nutrition/cancer and
lifestyle/obesitylifestyle/obesity
 367,000 individuals followed for 5 ± 2367,000 individuals followed for 5 ± 2
yearsyears

EPIC - PANACEA
 Traditional mediterranean diet: includesTraditional mediterranean diet: includes
olive oilolive oil
 Adapted mediterranean diet: includesAdapted mediterranean diet: includes
vegetable oilsvegetable oils
 Questionnaires on 9 diet componentsQuestionnaires on 9 diet components
with a scoring system to assess adherencewith a scoring system to assess adherence
to the mediterranean modelto the mediterranean model

EPIC - PANACEA
 Both traditional and adaptedBoth traditional and adapted
mediterranean diets are protectivemediterranean diets are protective
against weight gainagainst weight gain
 More benefit in youngest individualsMore benefit in youngest individuals
 More benefit in Southern EuropeMore benefit in Southern Europe
(Greece, Italy and Spain)(Greece, Italy and Spain)

Obesity: an ongoing battleObesity: an ongoing battle

Health in Italy: obesity
Italy Vs. fattest nations in the worldItaly Vs. fattest nations in the world
0
20
40
60
80
100
% overweight 44 68 69 74 90
Italy Greece Egypt USA
Tonga,
Samoa
2007 estimates

EU adults smoke and obesity 2009

Obesity: latest data and trends
 In Italy obesity and overweight haveIn Italy obesity and overweight have
increased with a tendency to stabilizeincreased with a tendency to stabilize
since 2005 (ISTAT data)since 2005 (ISTAT data)
 overweight prevalence about 35%overweight prevalence about 35%
 obesity prevalence about 10%obesity prevalence about 10%
 obesity prevalence projected in 2025obesity prevalence projected in 2025
14%14% ((Società Italiana dell’Obesità (SIO) data)Società Italiana dell’Obesità (SIO) data)
 These figures are much less dramaticThese figures are much less dramatic
than in USA. In 2005 60.5%than in USA. In 2005 60.5% ofof
American adults were overweightAmerican adults were overweight,,
23.9% obese, and23.9% obese, and 3.0% morbidly obese3.0% morbidly obese..

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 (Okkio2009 survey on 8-year old children (Okkio
salute):salute):
 11.1% obese11.1% obese
 22.9% overweight22.9% overweight
 Geography: combined prevalenceGeography: combined prevalence
in Campania 49%in Campania 49%
in Valle d’Aosta 23%in Valle d’Aosta 23%

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 areIn 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 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 forIn early afternoon, soap opera time for
housewives, there are more commercials onhousewives, there are more commercials on
 sweet drinks, snacks, cheeses andsweet drinks, snacks, cheeses and
merendinemerendine
ANDAND
 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 ads
junk food
Food ads as % of ads; junk as % of food
Caroli 2001

Obesity in Italy - dieting
Source: Istututo Auxologico Survey 1999
overweight obese general
population
prevalence
13
18
11
0
2
4
6
8
10
12
14
16
18

Methods to loose weight in
Italy
D’Amicis, Physical Activity Survey 1998
0 20 40 60 80
Diet
gym
diet & gym
drugs
other
nothing
women
men

What Italians do about obesity?
 Nothing: 30%Nothing: 30%
 Self-dieting: 14%Self-dieting: 14%
 Consult nutritionist or physician at leastConsult nutritionist or physician at least
once: 56%once: 56%
 60% don’t know the Mediterranean diet60% don’t know the Mediterranean diet
characteristicscharacteristics
2009 ISTAT survey

Obesity day
 Every year since 2001Every year since 2001
 More than 150 centersMore than 150 centers
nationwidenationwide
 Practical info on obesityPractical info on obesity
to the general publicto the general public
 Promotion of obesityPromotion of obesity
clinics in public hospitalsclinics in public hospitals

Obesity: the Italian weaponsObesity: the Italian weapons

Diet therapy debate in Italy
 biologists can only suggest dietarybiologists can only suggest dietary
guidelines to improve health but cannotguidelines to improve health but cannot
prescribe a therapeutic diet which shouldprescribe a therapeutic diet which should
exclusively given by physicians (Italianexclusively given by physicians (Italian
Supreme Court 2011)Supreme Court 2011)

History of popular diets
Dissociated (HayDissociated (Hay
1930)1930)
Very popular in Italy - separation betweenVery popular in Italy - separation between
proteins and carbohydratesproteins and carbohydrates
Weight WatchersWeight Watchers
(J. Nidetch 1960)(J. Nidetch 1960)
In Italy since 1973. Italian version: DietaIn Italy since 1973. Italian version: Dieta
punti (Razzoli) very popular in the pastpunti (Razzoli) very popular in the past
Atkins (1972)Atkins (1972)
ScarsdaleScarsdale
In Italy brief popularity of version based onIn 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 versionRecently popular in the hard version
(minestrone)(minestrone)
Beverly HillsBeverly Hills
(Mazel, 1980)(Mazel, 1980)
manymany
Herbalife (1980)Herbalife (1980) Italian version - multilevel marketingItalian version - multilevel marketing

History of popular diets
MediterraneanMediterranean
(1990)(1990)
Often prescribed by nutritionistsOften prescribed by nutritionists
MontignacMontignac 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, veryItalian version now popular – low fat, very
high proteins – no scientific data, “one ofhigh 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 followrules are complicated and difficult to follow
on a long term periodon a long term period
 In human nutrition, psychological aspects areIn human nutrition, psychological aspects are
essentialsessentials
 We prefer tastes, smells and situationsWe prefer tastes, smells and situations
associated with past happy memoriesassociated with past happy memories
 The best prevention of obesity is to eat withoutThe best prevention of obesity is to eat without
disrupting our emotionsdisrupting our emotions

 Typical Mediterranean dietTypical Mediterranean diet
 Proteins 15% fats 25% carbsProteins 15% fats 25% carbs
60%60%
 Corrected Mediterranen dietCorrected Mediterranen diet
 Proteins 20% fats 25% carbsProteins 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

 Typical Zone dietTypical Zone diet
 Proteins 30% fats 30% carbs 40%Proteins 30% fats 30% carbs 40%
 Carbs: relatively more fruits andCarbs: relatively more fruits and
vegetables, much less starches, barley, oatvegetables, much less starches, barley, oat
 Fats: olive oil, more Omega-3Fats: olive oil, more Omega-3
 ““When compared to all of the popular diets, theWhen compared to all of the popular diets, the
Mediterranean diet is the most similar to the Zone inMediterranean diet is the most similar to the Zone in
terms of balance and moderation coupled with commonterms of balance and moderation coupled with common
sense.You should consider the Mediterranean diet as asense.You should consider the Mediterranean diet as a
less sophisticated version of the Zone. “less sophisticated 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 overweightNewly diagnosed diabetics who were overweight
better managed their disease by eating abetter managed their disease by eating a
Mediterranean diet rich in fish, fruits andMediterranean 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 carbCombination 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 coffee
D: swordfish and coffeeD: swordfish and coffee
 BF: pasta oil redpepper and coffeeL:BF: pasta oil redpepper and coffeeL:
chicken breast and coffeeD: sole andchicken breast and coffeeD: sole and
coffeecoffee
 BF: artichokes and coffeeL: beef andBF: artichokes and coffeeL: beef and
coffeeD: fish and coffeecoffeeD: fish and coffee

The last craze:
the TISANOREICA
 Another variationAnother variation
of ketogenic dietof ketogenic diet
 Package withPackage with
proteinprotein
supplements andsupplements 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:
 Followed by VIP: BerlusconiFollowed by VIP: Berlusconi

The last craze:
 Followed by VIP: WittstockFollowed by VIP: Wittstock

Dimagenina
 Intragastric BulkingIntragastric Bulking
Agent – non-Agent – non-
prescriptionprescription
 2-3 capsules before2-3 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 commerciallyVery recent and commercially
successful modality offered in a somesuccessful modality offered in a some
Italian centersItalian centers
 Nasogastric tube feeding of proteinsNasogastric 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 aminoacid2 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 enteralIn addition to enteral
feeding:feeding:
 Proton pumpProton pump
inhibitorsinhibitors
 LaxativesLaxatives
 VitaminsVitamins
 mineralsminerals

NEC protocol
 Cycles of 10 days withCycles of 10 days with
3-week intervals3-week intervals
 Claimed weight lossClaimed weight loss
 9-13% in the first9-13% in the first
cyclecycle
 7- 10% in the7- 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 vs diet: SOS 2010

Number of bariatric procedures : 18,363Number of bariatric procedures : 18,363
Number of centers: 122Number of centers: 122
SICOB Registry – June 2011

SICOB Registry – 2011
types of procedures

SICOB Registry – 2011
mortality

 Purely restrictivePurely restrictive
 Endoscopic placement andEndoscopic placement and
removal with sedationremoval with sedation
 Temporary measure limitedTemporary measure limited
to six monthsto six months
 Not yet FDA-approved inNot yet FDA-approved in
USAUSA
500-600 ml saline
with methylene blue
Intragastric balloonIntragastric balloon

To collect italian experience on BIB
18 centers18 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
RESULTSRESULTS ( n = 3824)( n = 3824)
6 months BMI: 36.96 months BMI: 36.9±±6.4 (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 OcclusionGastric Occlusion 19 (0.49%)(0.49%)
Gastric PerforationGastric Perforation 5 (0.13%) **
Gastric UlcerGastric Ulcer 10 (0.26%)
Bowel OcclusionBowel Occlusion 3 (0.07%)
3737 / 3824 (0.96%)/ 3824 (0.96%)
(Prior Gynecological surgery)(Prior Gynecological surgery)

M/F 301/652
Age 37.5 (19-69) years
BMI 41.2 (30.7-56.5) kg/m2
%EW 61.3 % (34-117.6)
March 1998 – June 2009
1,010 placements
BIB - Policlinico Umberto I
Dr. Genco’s series

Female
Age < 35 years
BMI < 40
Predictive Factors
P < 0.05
EWL%:EWL%: nsns
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 %
% Pts
Post-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%

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

Meta-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

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
Dumonceau EBM review Obes Surg 18:1611, 2008

2-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
BMI
BIB removal
p = 0,04
BMI
BIBBIB
DIETDIET

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 Fisheran Fisher in thein the NewNew
York Times,York Times, DecemberDecember
13, 200713, 2007

Carb obesity and food culture in italy 2012

Carb obesity and food culture in italy 2012

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