España: El País Más Sano del Mundo. ¿Hasta Cuando?

A principios de 2019 España fue nombrado el país más sano del mundo, sí, ¡en serio! (1) Si la imagen de este país ahora mismo es la de un país sano, donde todo el mundo come bien y vive hasta 100 años, el futuro no es tan atractivo. Hace un mes, la organización World Obesity (traducido como Obesidad Mundial) lanzó su atlas global de obesidad infantil (2), en el cual lista información sobre los porcentajes de obesidad en niños y niñas de 5 a 9 años y 10 a 19 años. También se listan los datos de porcentaje de mujeres que fuman y los porcentajes de adolescentes que no hacen suficiente actividad física.

En el 2013 en la Asamblea de Salud Mundial (World Health Assembly), 193 países acordaron que los niveles de obesidad infantil en el año 2025 no deberían superar de los niveles del 2010 – 2012. Pero, por desgracia, el documento de este año nos informa de que 80% de esos países tienen una probabilidad de cumplir ese reto por debajo de 10% y, ningún país tiene una probabilidad por encima de 50% de cumplirlo. En otras palabras, hace 6 años el mundo acordó frenar el crecimiento de obesidad infantil y, lo más probable, es que nadie lo consiga.

Los datos de España son los siguientes

% de niños con la edad 5-9 con obesidad en 2016	17.9%
% de niñas con la edad 5-9 con obesidad en 2016	12.1%
% de niños con la edad 10-19 con obesidad en 2016	10.6%
% de niñas con la edad 10-19 con obesidad en 2016	6.3%
% de niños adolescentes que no hacen suficiente actividad física en 2010	69.7%
% de niñas adolescentes que no hacen suficiente actividad física en 2010	84.3%
% de mujeres con obesidad en 2016	23.8%
Estimación de % de mujeres fumadoras en 2020	25.7%

Los colores no son así como un homenaje a la bandera de España, si no que representan números altos (rojo) y números medio-altos (amarillo).

Con estos datos de la situación actual, World Obesity asigna cada país una puntuación de riesgo (CHO Risk) que cuantifica el riesgo de cada niño y niña de tener obesidad. La puntuación máxima es 11 y España tiene 7.5, un riesgo alto según World Obesity.

Además de un reportaje de la situación actual, hay unas predicciones para el año 2030.

Predicción 2030 % de niños y niñas de 5-9 con obesidad	18.6%
Predicción 2030 % de niños y niñas 10-19 con obesidad	11.6%
Predicción 2030 numero de niños y niñas 5-9 con obesidad	383.815
Predicción 2030 numero de niños y niñas de 10-19 con obesidad	931.043

Con las predicciones de 2030, World Obesity le da a cada país una probabilidad de cumplir el objetivo de que los niveles de obesidad infantil en 2025 no sean más altos que en 2010-2012. España tiene una probabilidad de cumplir este objetivo de solo 18%.

En resumen, mientras que los niveles de obesidad infantil en España no son los más altos en el mundo, sí que son demasiados altos, y es muy probable que vayan a aumentar en los próximos 10 años. Un niño/a nacido hoy en España tiene una probabilidad del 68% de ser obeso/a. Otra estadística alarmante es la del porcentaje de niño/as que no hacen suficiente actividad física, especialmente las niñas. La actividad física es mucho más que una forma de controlar el peso corporal. Los beneficios son muchos y es imprescindible que encontremos una forma para aumentar los niveles de actividad física.   

En fin, decimos que España es el país mas sano del mundo, pero ¿no sería más correcto decir que España, en realidad, es el país menos insano?

Referencias
1. https://www.bloomberg.com/news/articles/2019-02-24/spain-tops-italy-as-world-s-healthiest-nation-while-u-s-slips
2. https://www.worldobesity.org/nlsegmentation/global-atlas-on-childhood-obesity

Sensibilidad al trigo

Hasta un 30% de las personas que padecen SII podrían ser sensibles al trigo. Según la literatura científica existe un subgrupo de pacientes que presentan síntomas de SII que en realidad tienen sensibilidad al trigo. Parece que además este subgrupo tiende a padecer más anemia y pérdida de peso que los que padecen SII y suelen tener una historía clínica de alergias alimentarias en la infancia (1).

Aún no está muy claro qué componente del trigo ocasiona los síntomas. Aproximadamente un 80% del trigo está formado por gluten, pero también tiene otro componente que puede jugar un papel fundamental en la aparición de síntomas: los fructanos. 

Los fructanos forman parte de una grupo de hidratos de carbono llamados FODMAP. Éstos son fermentados rápidamente y mal-absorbidos, ocasionando un aumento de agua en el intestino y un aumento del tránsito intestinal. Los FODMAP llegan al colon mínimamente alterados, donde son fermentados por bacterias, ocasionando gases y distensión abdominal (2).

Este estudio (3) mostró como personas que padecían sensibilidad al gluten no celíaca y SII dejaron de tener síntomas al ponerlos en una dieta baja en FODMAP, lo cual apoya la teoría de que son los FODMAP los que generan los síntomas, más que el gluten. 

Existen otros componentes del trigo, como los inhibidores de amilasa-tripsina, que también podrían jugar un papel importante, activando el sistema inmune-innato y la liberación de citoquinas inflamatorias (4).

Es importante que las personas con sensibilidad al trigo sean derivadas a un dietista (tanto por el médico de cabecera como por gastroenterólogos) ya que en la consulta el dietista establecer una dieta adecuada (ya sean sin gluten o baja en FODMAP y evitar restricciones innecesarias que puedan estar limitando la calidad de vida de estos pacientes. Por ejemplo, las personas con celiaquía que siguen una dieta sin gluten, tienden a tener una dieta en la que las ingestas de fibra y calcio están por debajo de las recomendaciones (5). Otro de los riesgos asociados con estas dietas es el desarrollo de desórdenes alimentarios como ortorexia nerviosa, que es algo que el dietista también debe tener en cuenta. 

A día de hoy todavía no está claro qué componente del trigo es el responsable, por lo que se necesitan estudios bien planteados. Ésto es particularmente difícil ya que los pacientes deben ser "cegados" (no saber qué están comiendo, si lleva gluten o no, si lleva FODMAP o no, etc.) y deben seguir una dieta determinada, sin saltársela en ningún momento durante un período de tiempo largo.



 
1. https://www.ncbi.nlm.nih.gov/pubmed/22825366 
2. https://www.ncbi.nlm.nih.gov/pubmed/28244663 
3. https://www.ncbi.nlm.nih.gov/pubmed/23648697 
4. https://www.ncbi.nlm.nih.gov/pubmed/25925932 
5. https://www.ncbi.nlm.nih.gov/pubmed/15882378

Thin Privilege: An Update

After another lively debate on Facebook regarding this topic I spent most of the other night thinking about it and my reaction to it. 
Is this where I suddenly repent and accept my thin privilege? No, it isn't. I still don't like the term, the concept and everything it entails and here is why.
When I read the original article and the comments associated with it it made me angry because deep down I didn't think I was getting any kind of privilege for being thin. Yes as a man, and although I really didn't want to bring race into it, a white man, I fully acknowledge the society we live in has been constructed in my favour. I accept that, and if it will change anything, which I doubt it will, I acknowledge that privilege. 

The comments I received mostly seemed to indicate that I was denying that "weight bias" "body diversity" "Sizeism" and so on existed, which was not the case. What I didn't like was first the assumption that people are "naturally thin", and that my life is easy because I am thin, You have no idea about my life just as I don't about yours, any assumption based on appearance is wrong. 
This point didn't seem to be accepted and I continued to receive anecdotes about people's lives and how they struggle with discrimination, which, at the risk of sounding like a stuck record I didn't deny existed.

After being directed towards research around weight bias and wages, a couple of points jumped out at me and made me rethink why I am reacting this way. 
In an article in the Journal of Applied Psychology (1) it was demonstrated that thinner women get paid more, not surprising, but the opposite was true for men. In fact, larger men get paid more up until the point of obesity. And a quote lifted from an article on Forbes (2) based on the study said. "Skinny men, indeed, are often regarded as nervous, sneaky, afraid, sad, weak, and sick, where men of well-proportioned build are associated with traits such as having lots of friends, being happy, polite, helpful, brave, smart, and neat." 

So is this really "Fat Vs Thin"? Or is it just another example of different rules for men and women?

I started thinking through my experiences in work and the times I've had to say "yes I do eat" or "no I am not addicted to heroin", did me being a thin man (as opposed to just thin) have something to do with this? 
Or the times I felt I wasn't taken seriously in staff meetings. I had always assumed it was because I was one of the youngest in the room (sadly no longer the case) but maybe it was because I was thin? 
While I can still find clothes that fit me in most shops I have noticed that I have had to drop down a size from M to S with no major change in body weight. It appears that provisions are being made to spare men's feelings by simply shifting everything up one size which is not happening for women. So is this really "thin privilege" or just plain old sexism? 
Is it possible that as a man "thin privilege" doesn't extend to me? Or at least not as much as it does for women? 

Rethinking where I stand on this topic I still reject the term thin privilege because I think it diverts away from the real issue which is what society expects of women. It looks like as a man I can put on a few kilos and not suffer any negative consequences, up to a point, whereas women cannot. And to me that is sexism not thin privilege. 

1. J Appl Psychol. 2011 Jan;96(1):95-112. doi: 10.1037/a0020860.
2. https://www.forbes.com/sites/freekvermeulen/2011/03/22/the-price-of-obesity-how-your-salary-depends-on-your-weight/#29a06bbb3d9a

No, we don’t need to talk about thin privilege

 Update: I have modified slightly my opinion on the term thin privilege which can be read here

This is an opinion piece by Wayne Bradley and does not reflect anybody else's views associated with this blog.

Recently I found myself in a debate with fellow nutritionists and dietitians on the Build Up Dietitians Facebook page regarding the concept of thin privilege. Thin privilege is as follows, we “thin” people live in a world where we don’t experience the stigma and prejudices that overweight people experience. We can find clothes easily, we don’t get stared at when we eat in public and so on. 

Ok, so far so good, nobody would argue with that fact. But I have several issues with labelling it “thin privilege”, firstly the word privilege and the tone of the articles I have read regarding this topic indicate that being thin, or “skinny” which gets thrown around lightly but no-one will dare say fat, is something that has been gifted to us, we haven’t earned it and we should thank our lucky stars that we’re in this position. 
Most people, especially those in the health & nutrition industry know only too well how hard maintaining/losing weight is and to hint that normal weight people are somehow blessed or “privileged” is quite insulting, but sadly nothing new. Now of course because I said I eat well and do a lot of exercise that also means I think every large person is bone idle and just eats pizzas all day long! No, it doesn’t! It means making ANY assumption about a person’s body shape is wrong. 

I feel very proud of myself when I see those scales going down, or when I get up 8am on a Sunday to go riding even though the sun is shining and I’d much rather have a few beers with my wife and friends. To suggest I should somehow feel privileged for that completely undermines the hard work and effort I (or anyone) does to maintain their healthy lifestyle. That doesn’t make me unaware of the battles large people go through, in fact, what I do with my life has nothing to do with what my patients do with theirs, which leads me on to my second issue.  

My second issue is also to do with the term “thin privilege”. It is a nonsense term and completely unnecessary. When our patients come to visit us, they will discuss with us the problems they face, not only with their food choices but with self -esteem, health issues and so on. We will listen to them and if we do not share the same problems we will use empathy to understand them and guide our patients through their journey. 
We already have the word, it is empathy, we do not need a new Insta-trendy, buzzword. If as a healthcare professional you are unable to empathise with your patients then may I suggest a career change? Politics perhaps. 

To repeat a previous point, what I do with my life has no bearing on my patient's lives and has no place in a consultation. They are there to talk about their lives not mine. If the boot was on the other foot and my coach was "acknowledging" their superior athletic ability or shall we say "athletic privilege", I would feel extremely patronised and would probably sever ties with that coach very quickly. 

Perhaps I am being too pedantic around terminologies and the use of words. However, I worry that we are going down a particular path where we will not be able to openly discuss weight, obesity and its related health problems. Body size and shape should not be attributed to attractiveness, I will vigorously defend that there is not one "perfect" type of body in terms of what is "hot" or "sexy". We all have our own tastes and that is what makes the human race so amazing! However, obesity is not healthy, it just isn't. Many co-morbidities exist with obesity, we all know it and not discussing them does not make them go away. 

Saying "you're fat therefore ugly" is disgusting and should be stamped out immediately. But saying "you are overweight and need to make a change to improve your life" is not the same thing and should be what we are saying, but I fear we are becoming too scared of being labelled as "fat shamers". 

To repeat, I acknowledge that larger people have a tough time in regards to the society we live in, but as nutritionists/dietitians we are there to help them and we owe it to them to be honest. What use is saying "yeah I know I'm thin and my life is easier than yours"? 

During the debate, the topic of the genetic influence on body weight continued to appear, while it was beside my original point I will address it here.Yes genetics plays a large role in a person's size. The size of that role varies. However, does that mean we all just give up and say "its the genetics"? Because if that is the case then dietetics is dead!! I don't believe that is the case, some of us have been dealt a good hand in genetics, some haven't. That doesn't mean we can't make the best with what we've got. We can still strive to be the best version of ourselves and I strongly believe that externalising ourselves to the genetically thin and fat does us all a huge disservice. 

Wayne Bradley BSc (hons) MSc PG cert

Diagnosis of IBS: Breath Tests

One of the many frustrating aspects of irritable bowel syndrome (IBS) is it can appear quite vague and “un-scientific” when it comes to getting a diagnosis. In today’s modern world we expect diseases to be diagnosed rapidly and efficiently, we go to the Drs, they take some blood and a few days later we have our results. With IBS on the other hand, its lots of questionnaires, symptom diaries and trial and error.

One area that does appear, on the face of it, to offer a clear yes/no answer are breath tests. But how useful are breath tests when it comes to an IBS diagnosis?

What are breath tests?

Breath tests are used to determine whether you absorb or malabsorb a particular sugar. The tests offered are usually for lactose, fructose, sorbitol and mannitol. The patient will be given a dose of one the above sugars and then the amount of hydrogen and/or methane is measured in the patient’s breath. The understanding is that any of the sugars that are not absorbed are fermented by intestinal bacteria which produce the gases hydrogen and methane. The gases are carried in the bloodstream to the lungs where they are exhaled. A cut off point is established and if the amount of exhaled gas is above that point then the patient is diagnosed as “intolerant” to that sugar.

For an individual that suspects they may have IBS these tests appear very attractive because all of the mentioned sugars are associated with the condition plus the tests promise a quick and clear result.

But…..

Sadly here comes the but. While lactose intolerance is a recognised condition and the breath test to determine it well established, the same cannot be said for fructose, sorbitol and mannitol. One issue is the lack of standardisation of the test, different centres have different cut-off points so your diagnosis may be different depending on the centre’s cut-off point not the amount of hydrogen you produced in your test.

Focussing on fructose for a second, we all have a limited capacity to absorb fructose. That means that at a large enough dose every single one of us will malabsorb fructose. A study from way back in 1986 found that 8 out 10 healthy subjects malabsrobed a 50g dose of fructose, whereas only 1 out of the 10 malabsorbed the 15g dose (1). Another study in 2014 found similar results, in a group of 16 healthy (non IBS) participants, a 40g dose of fructose was shown to distend the small bowel with water and cause IBS type symptoms even though they were not IBS sufferers (2).

This means that depending on what dose they give you could be wrongly labelled as intolerant to fructose or even given a false IBS diagnosis. What has been shown is that some people are more sensitive than others to a single dose of fructose but to label them intolerant is probably an exaggeration.

In conclusion, while the idea of a quick test and diagnosis is very attractive, especially in a condition such as IBS where patients are usually desperate for a straight answer. The lack of standardisation of the tests and the fact that we all could be diagnosed as fructose “intolerant” at the right dose means that sadly breath tests are not a reliable way to get an IBS diagnosis.

References

1.  J J Rumessen and E Gudmand-Høyer, 1986. Absorption capacity of fructose in healthy adults. Comparison with sucrose and its constituent monosaccharides.Gut. 27 (10) 1161-1168

2.  Murray, K et al. 2014. Differential effects of FODMAPs (fermentable oligo-, di-, mono-saccharides and polyols) on small and large intestinal contents in healthy subjects shown by MRI. American Journal of Gastroenterology. 109 (1) 109-110

Gluten Sensitivity: Does it really exist?

In previous articles we have explained the difference between coeliac disease, wheat allergy and a third condition known as Non-Coeliac Gluten Sensitivity (NCGS). To briefly recap, as the name suggests, NCGS appears to be a condition where people who are neither coeliac nor allergic to wheat still report symptoms of bloating, loose stools etc. when consuming gluten containing foods. The mechanisms behind the condition are unclear, the immune system doesn’t appear to be involved but some researchers have suggested that NCGS may be a step along the path towards coeliac disease (1). Whilst we were completing the Monash FODMAP course another possible explanation was put forward to explain why people who have no immunological response to gluten still report gastrointestinal issues when eating gluten containing foods. What was interesting was that the explanation called into question the very existence of the condition of NCGS.

In recent years gluten free eating has become very popular and lots of pseudo-conditions are attributed to gluten. Although NCGS isn’t what we would call a pseudo-condition it has been proposed that it might be part of IBS and the culprit isn’t gluten after all. 

Fructans are chains of varying length of the sugar fructose, they are universally malabsorbed because we do not have the required enzyme in our body to break the chains into smaller fructose units. This leads to the fructans passing to the large intestine where they are fermented by the resident bacteria. This fermentation and the resulting gas production is usually well tolerated by non-IBS people but people with IBS tend to be highly sensitive to the fermentation of fructans and experience painful bloating and bowel distention. Foods that contain fructans are vegetables such as onion and garlic and of course wheat.

Monash University state that there is a lack of evidence that has managed to separate the effects of gluten from fructans so it is unclear which food component they are reacting to. Therefore, they do not recognise NCGS as a condition in itself and propose that people who report problems with gluten may in fact be IBS sufferers reacting to the fructans in wheat (2).

Now, this all sounds well and good, people can now relax and realise they weren’t sensitive to gluten after all. However, the problem lies in the practicality of it all. Finding a food that contains gluten but no fructans is virtually impossible, the only one we have found so far is sourdough bread or “masa madre” as it’s known here in Spain. During the fermentation process of sourdough bread, microorganisms such as Lactobacilli feed on the fructans and reduce their content in the finished product. The end result is that people who previously thought they were gluten-sensitive could enjoy sourdough bread, providing coeliac disease has been correctly excluded.

In conclusion, it appears that there is a lack of strong evidence to declare that NCGS is a condition in itself and people who report symptoms may be in fact IBS sufferers who are particularly sensitive to fructans. Aside from wheat, people who suspect they may fall into this category also need to keep in mind, onion, garlic, leeks and chickpeas.

For any more information on IBS or the Low FODMAP diet please get in touch via info@gabinetederueda.es

References 

1. Francavilla MD, et al. 2014, Clinical, Serologic and Histologic Features of Gluten Sensitivity in Children. The Journal of Paediatrics; 164: 463-7

2. https://www.monashfodmap.com/blog/the-truth-behind-non-celiac-gluten/