Universidad de Talca

Curso Internacional del PIFRECV

Agosto 22, 2006

Dietas Mediterrneas y Salud,

relacin con el Sndrome Metablico

Federico Leighton
Laboratorio de Nutricin Molecular
Pontificia Universidad Catlica de Chile
fleighto@bio.puc.cl

Dietas Mediterrneas

Definicin
Componentes activos
Actividades biolgicas de los polifenoles:
antioxidantes
otras (GLUT4, eNOS, sirtuinas, etc)

Chile es un pas Mediterrneo

Qu nos permite hablar de

mediterrneo en Chile?

Chile es un pas Mediterrneo

1. Clima Mediterrneo
2. Agricultura Mediterrnea
3. Cultura Mediterrnea
4. Estilo de Vida Mediterrneo
5. Salud Mediterrnea
6. Dieta Mediterrnea

CLIMA
MEDITERRNEO

Climas en el Mundo

1. Clima Mediterrneo
Se caracteriza por presentar inviernos relativamente

hmedos y veranos secos

Se da entre los 30 y 45 de latitud, en la costa
occidental de los continentes. Particularmente frente a
aguas fras

Chile es una de las 5 zonas en el mundo que

presentan clima mediterrneo:

Entorno del Mediterrneo en Europa y frica

California Central y Meridional en Norteamrica
Costa chilena en el entorno de Santiago en Sudamrica
Regin de Ciudad del Cabo en frica
Australia sur-occidental

1. Clima Mediterrneo

Entorno del
Mediterrneo

California

Chile

Fuente:

Sudfrica

Presentacin Inaugural Seminario Chile Potencia Agroalimentaria,

Alberto Montanari, Octubre 2004

Australia

Pases productores de aceite de oliva

Chile mediterrneo (30 - 45)

y regin del Maule

AGRICULTURA
MEDITERRNEA

2. Agricultura Mediterrnea

La agricultura mediterrnea no es especfica

de un grupo de pases en el mediterrneo
(Espaa, Grecia, Italia y Portugal)

Es el resultado de los condicionamientos

geogrficos, climticos, demogrficos y
culturales en los que se asienta

2. Agricultura Mediterrnea
Se define por sus
resultados, los
productos
mediterrneos:
Frutas y Verduras
frescas
Cereales
Leguminosas y Frutos
secos
Vino
Aceite de Oliva
y del mar....pescado

En contraste, la
agricultura continental,
se define por los
siguientes productos:
Semillas oleaginosas
Carne y leche de vacuno
Remolacha azucarera

Referencia: J. Lama de Espinosa en La agricultura mediterrnea en el siglo XXI, 2000

Chile Potencia Agroalimentaria

Fuente: Seminario Chile Potencia Agroalimentaria,
Alberto Montanari, Octubre 2004

Ranking Mundial de Exportaciones de Alimentos (MM USD)

HOY (2004):
N

Para el Bicentenario (2010):

Pas

2004*

1 Estados Unidos

39,667

2 Francia

28,147

3 Blgica

23,519

4 Alemania

20,512

5 Holanda

20,269

6 Canad

18,190

7 China

17,219

8 Espaa

15,379

9 Italia

14,582

10 Australia

12,998

11 Inglaterra

12,861

12 Brasil

11,307

13 Dinamarca

9,972

14 Tailandia

9,480

15 Mxico

8,960

16 Argentina

8,428

17 Chile

7,000

18 Nueva Zelanda

6,328

19 Irlanda

5,860

20 India

5,466

y 87%....

CULTURA
MEDITERRNEA

ESTILO DE VIDA
MEDITERRNEO

SALUD
MEDITERRNEA

5. Salud Mediterrnea

Los pueblos Mediterrneos tienen muy

buena salud
Los chilenos tenemos muy buena salud,
ciertamente salud a nivel de pases
desarrollados

5. Salud Mediterrnea
Expectativa de Vida Ajustada por Discapacidad (DALE 2000)

Fuente: WHO Report 2001

Years of Life Expectancy for Men 45 Years Old

33

Greece
Spain
UK
USA

32
31
30
29
28
27
26
25
1960

1965

1970

1975

1980

1985

1990

Trichopoulou & Lagiou, 1997

5. Salud Mediterrnea
Tasa Ajustada de Mortalidad por Enfermedades del Aparato Circulatorio
(muertes / 100.000)

Fuente: CVD infobase, 1997

Origen del trmino

Dietas Mediterrneas
Ancel Keys 1957
el estudio de los siete pases

Ancel Keys, enero 1961

A.K. muere Noviembre 20, 2004

a los 100 aos.

USA
Japan

7 Countries Study
1957-, Ancel Keys, Flaminio Fidanza

El Estudio de los Siete Pases

Mort.coronaria*
Colesterol (mM)

Creta
9
5.3

Ingesta (g/da)
Pan
Legumbres
Frutas
Pescado
Carne
Grasa
Alcohol

380
30
464
18
35
95
15

Mediterrneo EUA Holanda

184
420
574
5.0
6.1
6.0

Keys A y cols.; Am J Epidemiol 124: 1986

416
18
130
34
140
60
43

97
1
233
3
273
33
6

252
2
82
12
138
79
3

*= 10 aos/10,000 hombres 50-69 a

El Estudio de los Siete Pases

Lyon Diet Heart Study

(mediterranean 18:3 3 acid-rich diet)

Survival curves for combined cardiac death, nonfatal myocardial infarction, unstable angina,
heart failure, stroke, and thromboembolism. Log rank test using only the time of the first event.
Note the striking difference between the control and experimental groups within the first year
(P < 0.0001). Mediterranean diet recommendation and elevation of plasma 18:3 3 in
Experimental group.
Renaud et al 1995

DIETA
MEDITERRNEA

Caractersticas Comunes de las

Dietas Mediterrneas
baja en grasas saturadas;
alta en grasas monoinsaturadas;
balanceada en cidos grasos poliinsaturados
(omega-6 y omega-3);
baja en protena animal;
rica en antioxidantes: vitaminas y polifenoles;
rica en fibra.

Frutas y verduras
en abundante cantidad
Alimentos frescos
minimamente procesados
Aceite de oliva y vegetal como
principal fuente de grasa
Cereales integrales, principalmente,
pan y pastas, a diario
Legumbres, semillas, nueces
y frutos secos, diariamente
Productos lcteos, principalmente
fermentados, yogurt y quesos, consumidos
diariamente en forma moderada

Huevos: 1-4 por semana

Pescado: consumo moderado

(2-4 veces por semana)
Ave: consumo moderado
(2-4 veces por semana)
Carnes rojas grasas: consumo en pequea
cantidad o algunas veces al mes
Vino: consumo moderado
(1-2 copas da) y en forma regular,
principalmente con las comidas
Uso habitual de especias y
condimentos variados como limn, vinagre,
ajo, hierbas aromticas, organo, etc.

General Conclusion:
Present evidences suggest that Wine phenolics,
other Plant phenolics, and -3 fatty acids
(18:3 3) constitute key elements in the healthy
effects of the Mediterranean Diets.
Besides their antioxidant capacity, plant
phenolics exert many other biochemical effects.

Effects on mammalian enzyme systems

Effects on mammalian enzyme systems

Middleton et al, Pharmacol Rev 2000

A. Kinases
B. Phospholipase A2
C. ATPases
D. Lipoxygenases and
cyclooxygenases
E. Phospholipase C
F. Cyclic nucleotide
phosphodiesterase
G. Adenylate cyclase
H. Reverse transcriptase
I. HIV-1 proteinase
J. HIV-1 integrase
K. Ornithine decarboxylase
L. Topoisomerase
M. Glutathione S-transferase
N. Epoxide hydrolase
O. Glyoxalase
P. Xanthine oxidase
Q. Aromatase

R. 11-b-Hydroxysteroid dehydrogenase
S. Catechol-O-methyltransferase
T. Aldose reductase
U. Monoamine oxidase (FAD-containing)
V. Aldo-keto-reductase family of enzymes
W. Hyaluronidase
X. Histidine decarboxylase and DOPA decarboxyl.
Y. Malate dehydrogenase
Z. Lactic dehydrogenase and pyruvate kinase
AA. Aldehyde and alcohol dehydrogenases
BB. Amylase
CC. RNA and DNA polymerases
DD. Human DNA ligase I
EE. Ribonuclease
FF. Sialidase
GG.Cytochrome P450 systems
HH. Elastase
II. Nitric-oxide synthase
JJ. ECA

Polyphenols and Aging genes

Longevity and
decreased Cardiovascular Risk:
are they two partly independent phenomena
resulting from dietary polyphenols?

Caloric restriction extends life-span in many

species, including rodents, flies, nematodes
and yeast. Data for primates due in the next
ten years, so far, extremely promising!

40 kcal/week
50 kcal/week
85 kcal/week
Ad-libitum

Weindruch, Science (1996) 273:59

Caloric Restriction and Longevity

Caloric Restriction extends life-span in many species,

including rodents (mice), insects (Drosophila
melanogaster), nematodes (Cenorhabditis elegans), and
yeast (Saccharomyces cerevisiae).
Caloric Restriction in yeast, apparently acts through
activation of sirtuin (Sir2-like proteins) enzymes which
deacetylate histones slowing gene expression. NAD is
the acetate acceptor.
Overexpression of sirtuin increases life-span in
S. cerevisiae and C. elegans.
Sir2 yeast mutants exhibit decreased life-span.
Humans have seven sirtuin genes

Sirtuin is an enzyme associated to longevity. Its

activity increases lifespan.

A search of sirtuin activation compounds was

made, Howitz et al, Nature September 11,
2003. They tried approximately 50 different
polyphenols.

Among polyphenols present in wine and other

vegetals, approximately 15 were shown to
activate the enzyime Sirtuin, in yeast and
human cells.

Nature. 2003 Sep 11;425(6954):191-6

......Here we report the discovery of three classes of small molecules that

activate sirtuins. We show that the potent activator resveratrol, a polyphenol
found in red wine, lowers the Michaelis constant of SIRT1 for both the
acetylated substrate and NAD+, and increases cell survival by stimulating
SIRT1-dependent deacetylation of p53. In yeast, resveratrol mimics calorie
restriction by stimulating Sir2, increasing DNA stability and extending
lifespan by 70%. We discuss possible evolutionary origins of this
phenomenon and suggest new lines of research into the therapeutic use of
sirtuin activators.

A quest for longevity. Five hundred years ago, the Spanish explorer Ponce de Len
drank his way around the Florida coast during his expedition to find the legendary
fountain of youth.

El Sndrome Metablico

Definicin
Consecuencias
Patognesis:

hiptesis frecuentes
estrs oxidativo
defecto de eNOS

Metabolic Syndrome definition:

Alternative denominations:
(Syndrome X)
(Insulin Resistance Syndrome)

National Cholesterol Education Program (USA)

(NCEP)
Expert Panel on
Detection, Evaluation, and Treatment
of High Blood Cholesterol in Adults

(Adult Treatment Panel III, or ATP III)

94?
80?

100?

Changes associated with insulin resistance,

(with metabolic syndrome):
Inflammatory markers:
Lifestyle:
Cigarette smoking
Sedentary behaviour
Lipoproteins:
Increased apo B
Decreased apo A-1
Small dense LDL and HDL
Increased apo C-III

Increased white blood cell count

Increased interleukin 6
Increased tumour necrosis factor
Increased resistin
Increased C-reactive protein
Decreased adiponectin
Vascular:
Microalbuminuria
Increased asymmetric dimethylarginine

Other:
Prothrombotic:
Increased uric acid
Increased homocysteine
Increased fibrinogen
Non-alcoholic steatohepatitis
Increased plasminogen activator inhibitor 1 Polycystic ovaries syndrome
Increased viscosity
Obstructive sleep apnoea
(Increased FFA)
Eckel et al. Lancet 2005

Prevalence of the Metabolic Syndrome

Prevalence of the metabolic syndrome from ATPIII definition

Eckel et al. Lancet 2005

SEMINARIO

Mediterrneas

PAM-Chile Programa Alimentario Mediterrneo en Chile

Pathogenesis of the Metabolic Syndrome (2004)

The metabolic syndrome seems to have 3 potential etiological
categories:
-obesity and disorders of adipose tissue
-insulin resistance
-and a constellation of independent factors
that mediate specific components of the
metabolic syndrome (eg, molecules of hepatic,
vascular, and immunologic origin).
Other factorsaging, proinflammatory state, and hormonal
changeshave been implicated as contributors as well.
Definition of Metabolic Syndrome. Report of the National Heart, Lung,
((Oxidative stress???))
and Blood Institute/American Heart Association Conference on
Scientific Issues Related to Definition

Scott M. Grundy, MD, PhD; H. Bryan Brewer, Jr, MD; James I. Cleeman, MD; Sidney
C. Smith, Jr, MD; Claude Lenfant, MD; for the Conference Participants*
(Circulation. 2004;109:433-438.)

METABOLIC SYNDROME

Obese Woman

Normal Woman

Age:

Age:

40 yrs

36 years

Weight: 113 Kg

Weight: 54 Kg

Height: 1.68 m

Height: 1.65 m

BMI:

BMI:

40.3
Patient

Control

20.0

National Geographic, Agosto 2004

Glucose Utilization (mg/kg LBM/min)

Relationship among visceral adipose

tissue and insulin action
18
16
14

Banerji et al. Am J Physiol. 1997;273:E425-E432.

Women
Men

12
10
8
6
4
2
00

2,000
3,000
5,000
1,000
4,000
Volume of Visceral Adipose Tissue per unit of surface
(mL/m2)

Pathophysiology of the metabolic syndrome (insulin resistance)

A: Free fatty acids (FFA) are released in abundance from an expanded adipose tissue mass. In the liver, FFA lead to
an increased production of glucose, triglycerides and secretion of very low density lipoproteins (VLDL). Associated
lipid/lipoprotein abnormalities include reductions in high density lipoprotein (HDL) cholesterol and an increased
density of low density lipoproteins (LDL). FFA also reduce insulin sensitivity in muscle by inhibiting insulin mediated
glucose uptake. Associated defects include a reduction in glucose partitioning to glycogen and increased
lipid accumulation in triglyceride (TG). Increases in circulating glucose and to some extent FFA increase pancreatic
insulin secretion resulting in hyperinsulinemia. Hyperinsulinaemia may result in enhanced sodium reabsorption
and increased sympathetic nervous system (SNS) activity and contribute to the hypertension as might increased
levels of circulating FFA.

Eckel, Grundy, Zimmet et al. Lancet vol 365 (April 16, 2005)

Pathogenesis of the MS
Oxidative stress is also a key pathogenic element.
Further comments on Oxidative Stress and Metabolic Syndrome:
eNOS relates to oxidative stress because it can generate superoxide,
when uncoupled, and because its product, NO, requires antioxidant
protection
Oxidative Stress in MS is present, and a special role for adipose tissue
oxidative stress has been proposed
(Leighton et al, OIV, Vienna, July, 2004; Furukawa et al, December 2004)

Oxidative Stress in MS Patients, Basal Values

and Endothelial Function

Leighton et al, OIV, Vienna, July 4-9, 2004

Increased Oxidative Stress in obesity

and its impact on the Metabolic
Syndrome

Furukawa et al, The Journal of Clinical Investigation 114 (December) 2004

Pathogenesis of the MS

A breakthrough in the study

of MS pathogenesis!

Pathogenesis of the MS

Clustering of cardiovascular risk

factors mimicking the human
metabolic syndrome X in eNOS null
mice
Results:

.....eNOS/ mice were hypertensive and insulin resistant,

....eNOS/ mice had a 1.5 to 2-fold elevation of the
cholesterol, triglyceride and free fatty acid plasma
concentration.
Even though body weight was comparable, the leptin plasma
level was 30% higher in eNOS/ than in wild type mice.
On a high fat diet, knock-out mice became significantly more
glucose
intolerant than control mice.
S. Cook, O. Hugli, M. Egli, P. Vollenweider, R. Burcelin, P. Nicod, B.
Thorens, U. Scherrer SWISS MED WKLY 2003;133:360363

Blood pressure
Fasting insulin

Glucose infusion
rate

FFA
Triglycerides
Cholesterol

S. Cook, O. Hugli, M. Egli, P. Vollenweider, R. Burcelin, P. Nicod, B.

Thorens, U. Scherrer SWISS MED WKLY 2003;133:360363

Pathogenesis of the MS

Conclusions:
A single gene defect, eNOS deficiency,
causes a clustering of cardiovascular risk
factors in young mice.

We speculate that

defective nitric oxide synthesis could

trigger many of the abnormalities making
up the metabolic syndrome in humans.
S. Cook, O. Hugli, M. Egli, P. Vollenweider, R. Burcelin, P. Nicod, B.
Thorens, U. Scherrer SWISS MED WKLY 2003;133:360363

If defective (absent) eNOS causes Metabolic Syndrome in mice,

how could we explore it genetically in humans?

A possibility is to explore if polymorphisms (mutations)

of the eNOS gene in humans, cause defects related to
Metabolic Syndrome.
The answer is yes, genetic modifications of eNOS
associate with changes such as:
Ischemic heart disease
Diabetes type 2
Hypertension

Pathogenesis of the MS
Scientific data supports a central role for eNOS in the pathogenesis
of the Metabolic Syndrome:
eNOS (-/-) mice: Ins Resist, Hypertension, high TG, high Fibrinogen
eNOS (+/-) mice with high fat: Hypertension and Ins Resist
eNOS relates to T2Diabetes and Ins Resist in humans
eNOS polymorphism and hypertension in humans
eNOS (-/-) mice: muscle mitoch. deficit, reduced phys activity
eNOS responds to estradiol (HDL)
eNOS triggers cGMP-dependent mitoch. biogenesis
eNOS is a potential source of free radicals (O2-)
eNOS involved in MS characteristic erectyle disfunction
previous speculations for: CV disease, diabetes, late ischemic
preconditioning, platelet activation,
inflammatory and ox stress in CV patients

Pathogenesis of the MS
Scientific data supports a central role for eNOS in the
pathogenesis of the Metabolic Syndrome:
But, the different mechanisms through which eNOS
dysfunction could lead to MS, as well as the various
mechanisms linking wine and health to the correct
function of eNOS and consequent positive effects on
plasma lipids, haemostasis, endothelial function, and
reduced oxidative stress, remain to be established.
Oxidative stress in Metabolic Syndrome is today a
key question.

Comparacin experimental de la
Dieta Mediterrnea
con la
Dieta Occidental

STUDY DESIGN

MEDITERRANEAN
n=21

HIGH-FAT
n=21

30

60

90

Time (days)

DP 08-98

TOTAL ANTIOXIDANT REACTIVITY (TAR)

M Trolox equivalent

*c

*
b

*
b
*
B
*
A

*
A

30

60

90

High Fat diet

30

60

90

Mediterranean diet
Time (days)
DP 06/2000

Plasma Polyphenols
12

M Rutin equivalent

10
8

ab

B
a

AB

4
2
0
0

30

60

90

High Fat diet

30

60

90

Mediterranean diet
Time (days)
PS 6-2000

Oxidative DNA damage

8-Hydroxydeoxyguanosine

8-OhdG/105 dG

14
12

10
A
8

6
*

ab

b
c

2
0-

30

60

90

High Fat diet

30

60

90

Mediterranean diet
Time (days)

PS 6-2000

ENDOTHELIAL FUNCTION:
A link between ethanol effects
and antioxidants?
An additional function for wine
phenolics?

Hyperhomocysteinemia
Estrogen deficit
Hypercholesterolemia
(oxidized LDL)

Hypertension

Smoking

Diabetes

NO

ENDOTHELIAL DYSFUNCTION

ATHEROSCLEROSIS

MEASUREMENT OF ENDOTHELIAL FUNCTION

(flow mediated vascular reactivity)

ENDOTHELIAL FUNCTION
(measured after 12 hours without wine and food)

DIAMETER CHANGE (%)

HIGH FAT DIET

WITHOUT
WINE

WITH
WINE
Cuevas, Leighton et al
Lipids 35: 143-148, 2000

Endothelial Function in a High-Fat Diet Intervention study

12
b
ab

10

Percent diameter change

b
b

8
a
6

a
time

4
a

DIET
WHITE W

RED W
0

MUFA

PUFA

F&V

arginine + O2

NADPH

eNOS
NADP+

citrulline + NO. + O.2

ONOO

Red Wine Polyphenol Extract increases NO production

in Human Endothelial Cells

Leikert et al, Circulation, 2002

Red Wine Polyphenol Extract enhances transcription of eNOS

in Human Endothelial Cells
(Leikert et al, Circulation, 2002)

Polyphenols
Polyphenols
Ca++

Ca++

Arginine

Arginine

Thrombosis
platelets

NO

CD36
caveolae

SRBI

NUCLEUS

?
estrogen
receptor

NO

eNOS

Endothelial
function
LDL
HDL
estrogen

El Sndrome Metablico y
las Dietas Mediterrneas
Papel central de la eNOS
Estudios de intervencin
Programa de Alimentacin Laboral

2006; 24(4): 291-298

Leighton et al, 2005-6

 Wine as eNOS enhacer

-Wine phenolics

(Miranda-Rottmann, Leighton et al 2003;

Leikert et al 2002; Martin et al 2002)

Other eNOS enhacers

-Mediterranean Diet

(Leighton et al 2000; Esposito et al 2004)

-Exercise
-PPAR gamma agonists

(Green et al 2004)
(Cho et al 2004; Hwang et al 2004)

Es reversible el Sndrome
Metablico?

SEMINARIO

Mediterrneas

Tenemos evidencias que el Sndrome

Metablico es por falla de una enzima
(la eNOS)
Esta enzima se activa con la dieta
mediterrnea:
Flavonoides
Antioxidantes
cidos grasos omega-3

PAM-Chile Programa Alimentario Mediterrneo en Chile

Katherine Esposito et al
JAMA, September 22/29, 2004Vol 292, No. 12

Effect of a Mediterranean-Style Diet on Endothelial

Dysfunction and Markers of Vascular Inflamation

90
assigned to recieve a
Mediterranean-style diet
180 patients with
Metabolic Syndrome
99 men
81 women

2 years
follow up
90
assigned to recieve a
control prudent diet

Esposito et al., JAMA 2004

Changes in number of components of

Metabolic Syndrome after 2 years
Mediterranean-style
Diet Group

Control Diet Group

from Esposito et al., JAMA 2004

Changes in Endothelial Function after 2 years

p < 0.001

p = 0.09

Baseline
After 2 years

Esposito et al., JAMA 2004

Desarrollos futuros

SEMINARIO

Mediterrneas

Ante las evidencias que la agroindustria

chilena puede aportar alimentos saludables,
y producir ms si es necesario
Dada la alta incidencia de factores de riesgo
propios del Sndrome Metablico en la
poblacin adulta en Chile
Y considerando nuestro expertise y el de
nuevos asociados
PAM-Chile Programa Alimentario Mediterrneo en Chile

Desarrollos futuros

SEMINARIO

Mediterrneas

En la Universidad Catlica (VIII 2005)hemos

creado el Programa de Alimentacin
Laboral
Su objetivo es optimizar los recursos destinados
a la alimentacin laboral, promoviendo salud,
bienestar y estilo de vida
Luego hemos firmado (VI 2006) con DOLE y la
Asociacin Chilena de Seguridad un acuerdo
para la aplicacin de este programa en Chile
PAM-Chile Programa Alimentario Mediterrneo en Chile

Desarrollos futuros

SEMINARIO

Mediterrneas

En el ao 2006 hemos puesto en marcha el

PAL, un modelo capaz de generar las
evidencias cientficas necesarias para abordar
el problema a nivel nacional. Esto sera posible
ya desde 2007, sobre evidencias cientficas.

PAM-Chile Programa Alimentario Mediterrneo en Chile

Federico Leighton P.
18 de julio de 2006