Outline Paper. Topic: Obesity

What should be written in the YELscan 3LOW page the outline (write it in the same order in a doc):

Thesis Statement: There are three key strategies for an obese person to loss weight.

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1- Topic sentence ( diet ) write information from the article.

One supporting point for the first topic sentence from the article to support your topic sentence.(Quote as an evidence from the article)

2- Topic sentence ( exercise ) write information from the article

One supporting point for the second topic sentence from the article to support your topic sentence.(Quote as an evidence from the article)

3&4- Topic sentence ( harmful things ) information from the article

One supporting point for each third and fourth topic sentence from the article to support your topic sentence.(Quote as an evidence from the article)

Concluding sentence: You will write the concluding sentence.

References page: Each source cited in the outline must have a References page entry.


Link that shows you how to do the refrence page in case you didnt know how to do it:


The instruction from teacher as it is but you need to also follow the above instructions:

Outline (yellow page) write four main ideas with supporting points from the four articles. Follow the above order and ideas.


Each supporting point should have evidence connected to it in the form of a quote or paraphrase (what you will use as your quote sandwich later). Include a citation for each piece of evidence.


References page: Each source cited in the outline must have a References page entry.CLINICAL INQUIRIES From the Family Physicians Inquiries Network How do exercise and diet compare for weight Evidence-based answer Exercise alone produces short-term weight loss that is comparable with that induced by diet, after which a plateau in weight loss appears to occur (strength of recommendation [SOR]: B). Exercise in combination with diet promotes maintenance of weight loss above either intervention alone in both obese and overweight men and women (SOR: A). Exercise-induced weight loss has been Clinical commentary shown to preferentially reduce abdominal fat and increase lean skeletal muscle compared with that induced by diet (SOR: B). Multiple short bouts of exercise per day are as effective as a single long bout in producing weight loss (SOR: B). Adherence improves when exercise can be completed at home or home equipment is used (SOR: B). The real challenge: Motivating patients to exercise The evidence is pretty clear. The real challenge is motivating patients to start and maintain an exercise plan. The key points I make with my patients are: Aim for 5 to 7 times each week. Start slowly I Evidence summary Exercise vs diet: Some conflicting results Studies comparing the effectiveness of exercise and diet in weight reduction have yielded conflicting results. Earlier studies, including a meta-analysis and randomized (noncontrolled) study, favored interventions that included caloric restriction (diet alone or diet plus exercise).^’^ However, subjects on caloric restriction regained a significant amount of weight over time (0.9 kg ± 7.7 at 2-year follow-up). Subjects who did (10 minutes per session) and gradually build (at least to 20 minutes within a few months). Walking is often preferred, but do what you enjoy. Having a “buddy” work out with you may help you stick with it. Henty Domke, MD St. Mary’s Health Center, Jefferson City, Missouri aerobic exercise but did not diet lost less weight initially (0.7 kg ± 2.8) but maintained their weight loss better than those who dieted or dieted with exercise. These earlier studies failed to control for the confounding variable of energy balance—that is, ensuring the amount of calories reduced was comparable with the amount of calories burned through exercise between groups. A more recent randomized controlled trial suggests that aerobic exercise and caloric restriction are equally beneficial in reducing weight for obese men when controlling for negative energy balance.^ However, Stephanie Cudjoe, MD and Shannon Moss, PhD Baylor Family Medicine Residency at Garland, Garland, Texas Loan Nguyen, MD Baylor College of Medicine, Houston, Texas FAST TRACK Exercise alone is comparable with diet for short-term weight loss www.jfponline.com VOL 56, NO 10 / OCTOBER 2007 841 CO UJ cc O < o o How much exercise is best? Government agencies weigh in PHYSICAL ACTIVITY LEVEL Moderate Vigorous (altemative)! DHHS” NHLBI’ Moderate Moderate ACTIVITIES Bicyciing 5-9 mph, level terrain or with a few hills, brisk walking, golf, mowing lawn, recreational j swimming, scrubbing floors/washing windows, tennis (doubles), weight lifting/Nautilus machines/free weights Bicycling more than 10 mph or on steep uphill terrain, circuit training, moving/pushing furniture, mowing lawn (hand mower), racewaiking, jogging, running, swimming laps, tennis (singies) Bicycling (<10 mph), dancing, golf, hiking, light gardening/yard work stretching, walking (3.5 mph), weight iifting (general light workout) Basketball, bicyciing 5 miies/30 min, gardening, running 10 min/mile, social dancing, swimming laps, walking 15-20 min/mile DURATION 30 min FREQUENCY 5 or more days/week NOTES Ail adults 20 mm 60-90 min 30 min 3 or more days/week Daiiy Daily All adults All adults attempting to lose weight Ali adults FAST TRACK Exercising at home—or with a “buddy”—should help patients adhere to their regimen those who exercised experienced greater fat reduction and maintenance of skeletal muscle mass than those who only restricted calories. Similar findings regarding fat reduction have been reported elsewhere.”* Combining diet and exercise appears to be superior to diet alone, based on the results of a recent meta-analysis of randomized controlled trials.^ However, this meta-analysis did not specify type of exercise, so it is unclear whether outcomes varied by activity. Exercise: is there a dose-response relationsiiip? Several studies have looked at the relationship between duration and intensity for exercise and weight loss. A doseresponse relationship has been observed between the amount of time spent in aerobic exercise per week and the amount of weight lost for overweight women.^’^ There appears to be no significant difference in weight loss based on duration of a single aerobic exercise episode; rather, weight loss is similar whether completed in short or long bouts.^-^ One study found that at 12 months, individuals exercising more than 200 minutes per week lost 7.8 kg more (P<.01) than those exercising less than 150 minutes per week.^ Another study noted that at 18 months, subjects exercising more than 200 minutes per week lost 9.6 kg more than subjects exercising less than 150 minutes per week (P<.05).* Studies with energy expenditure, rather than time spent exercising, as the independent variable had similar results. At 18 months, individuals with higher energy expenditure (2500 kcal/week) lost 6.7 kg ± 8.1 compared with a mean loss of 4.1 ± 8.3 in subjects with lower energy expenditure (maximum of 1000 kcal/week).^ Recommendations from others The National Institutes of Health’s National Heart, Lung and Blood Institute,'” the US Department of Health and Human Services,” the Centers for Disease 842 VOL 56, NO 10 / OCTOBER 2007 THE JOURNAL OF FAMILY PRACTICE -e s s u r-e’ Patients should be counseled that this product does not protect against HIV intection.(AIDS) or other sexually transmitted diseases. IMPORTANT NOTE—This information is a BRIEF StJMMARY of the complete prescribing information (Instructions for Use) provided with the product and therefore should not be used as the basis for prescrltjing the product. This summary was prepared by deleting from the compiete Instructions for Use certain text, tables, arid references. The physician shouid be thoroughiy famiiiar with the complete Instructions for Use before using or prescribing this product. INDiCATIOhlS FOR USE: The Essure system is indicated for women who desire permanent birth controi (female sterilization) by biiaterai occiusion of the faiiopian tubes. CONTRAiNDICATIONS: The Essure system should not be used in any patient who: • is uncertain about her desire to end fertility • Can have only 1 micro-insert placed (inciuding patients with apparent contraiateral proximal tubai occiusion and patients with a suspected unicornuate uterus) • Has previously undergone a tubal iigation Or any patient with any of the foiiowing conditions: • Pregnancy or suspected pregnancy • Delivery or termination of a pregnancy iess than 6 weeks before Essure micro-insert piacement • Active or recent upper or iower pelvic infection • Known aiiergy to contrast media or known hypersensitivity to nickei confirmed by skin test WARNINGS: • The patient must use alternative contraception (cannot reiy on the Essufe micro-inserts for contraception) untii a hysterosaipingogram(HSG), which is performed 3 months post-micro-insert piacement, demonstrates satisfactory micro-insert iocation and tubai occlusion. During this time frame, the patient may be at an increased risk of ectopic pregnancy • The EssuK procedure should be considered irreversibie. There are no data on the safety or effectiveness of surgery to reverse the Essure procedure. Any attempt at surgicai reversai wiil iikeiy require uterotubai reimplantation. Pregnancy foiiowing such a procedure carries with it the risk of uterine rupture and serious maternai and fetal morbidity and mortaiity • The Essure micro-insert wiii conduct energy if directiy or closeiy contacted by an active eiectrosurgicai device, if this occ
urs, then there is a risk of patient injury. Theretore, eiectrosurgery shouid be avoided in procedures undertaken on the uterine cornua and proximai fajiopian tubes without either hysteroscopic visuaiization of the micro-inserts, or visuaiization of the proximai portion of the faiiopian tube via open surgical procedures or laparoscopy. During Laparoscopic Assisted Vaginai Hysterectomy (LAVH) and other procedures in which electrosurgicai instruments couid contact the serosa of the faiiopian tube, instruments should not be piaced more proximal than the ampuilary portion of the tube • Bench studies suggest that endometrial abiation using radio frequency (RF) energy wili cause significant damage to surrounding tissue if an active RF instrument comes into direct contact with the Essure micro-inserts. Consequently, if using RF energy to perform endometrial abiation, direct contact with the Essure micro-inserts shouid be avoided. Ciobai auto-abiative systems that empioy RF energy should not be used in women with the Essure micro-inserts in piace • Bencti and ciinicai studies demonstrated that thermal endometriai ablation of the uterus can be safely and effectiveiy performed with the Gynecare THERMACHOICE’ Uterine Baiioon System immediateiy foiiowing Essure micro-insert piacement. No specific studies have been conducted to evaiuate Essure expuision rates or contraception rates foiiowing fssure-THERMACHOICE procedures. No other thermal endometriai abiation teciinologies have been studied in conjunction with Essure ‘ There are no data regarding cryoabiation techniques or the use of iaser for endometriai abiation of the uterus with the Essure micro-inserts in place • There are aiso no data regarding the use of endometrial ablation devices that operate at microwave frequencies with the Essure rtiicro-inserts in piace. The use of microwave energy near metallic impiants has been shown to pose significant risk of serious injury to patients. Use of microwave endometrial ablation devices near the Essure micro-inserts therefore should be avoided • Aithough not reported in the ciinicai trials of the fssure system, there is a theoreticai increased risk of ectopic pregnancy in patients with the Essure micro-inserts, shouid they become pregnant • A very smali percentage of women in the Essure ciinicai triais reported recurrent or persistent peivic pain, and oniy 1 Vi^oman requested device rerrioval due to pain. However, if device removai is required for any reason, it wiil iikeiy require surgery, inciuding an abdominai incision and generai anesthesia, and possibie hysterectomy • Patients may decide, in future years, to undergo in vitro fertiiization (iVF) to become pregnant. The effects of the Essure micro-inserts on the success of iVF are unknown, if pregnancy is achieved, the risks of the micro-insert to the patient, to the fetus, and to the continuation of a pregnancy are also unknown PRECAUTIONS: • Women should be counseled that: —No contraceptive is 100% effective. Ectopic and intrauterine pregnancy can occur in contraceptive failure, even years after the procedure —Data on the Essure micro-inserts beyond 5 years are not yet avaiiabie and may be different from current data —Women who undergo steriiization at a reiativeiy young age are at greater risk of regretting their decision to undergo sterilization •Any intrauterine procedure performed without hysteroscopic visualization following Essure microinsert impiantation couid interrupt the abiiity of the Essure micro-inserts to prevent pregnancy. Foiiowing such procedures, device retention and iocation shouid be verified by hysteroscopy, x-ray, or ultrasound. In addition, the presence of the Essure micro-inserts can invoive risks associated with intrauterine procedures that, at this time, have not been identified • Performing endomefriat ablation irrimediately foiiowing piacement of Essure micro-inserts may increase the risk of post-ablation tubal sterilization syndrome, a rare condition that has been reported in women with a history of tubai steriiization who undergo endometriai ablation • Testing to ensure safety and compatibiiity with magnetic resonance imaging (MRi) has been conducted using a 1.5 testa magnet. The Essure micro-inserts were found to be MR safe at this fieid strength. Test resufe at 1.5 tesia indicate zero magnetic force and RF heating of 0.6°C in a phantom when a whoie body specitic absorption rate (SAR) of 1.3 W/kg was appiied. The presence of the micro-inserts produces an fvlR artifact, which wili obscure imaging of iocal tissue. The artifact is expected to be iarger at higher fieid strength ADVERSE EVENTS: A total of 745 women underwent the Essure procedure in 2 separate ciinicai investigations to evaiuate the safety and effectiveness of the fssuresystem (227 in the Phase II study and 518 women in the Pivotai triai). Some women underwent more than 1 procedure if successfui biiaterai piacement was not achieved in the initiai procedure. Placement of at least 1 Essure micro-insert was achieved in 682 women (206 in the Phase II study and 476 in the Pivotal triai). Adverse events, which prevented reiiance on the Essure device for contraception, were reported as foliows: failure to piace 2 micro-inserts in first procedure (14%), initiai tubai patency (3.5%), expuision (2.2%), perforation (1.8%), or other unsatisfactory device iocation (0.6%). Ail ot the patients who experienced tutial patency at the 3-month HSG were found to have bilateral occlusion at a repeat HSG performed at approximateiy 6 months after the Essure procedure. In addition, all of the patients wtio chose to undergo a second fssure procedure foiiowing a micro-insert expulsion achieved successfui micro-insert placement and were subsequently able to rely on the Essure micro-inserts for confraception. The most frequent adverse events and side effects reported as a result of the hysteroscopic procedure to piace the Essure micro-inserts were as foiiows: cramping (29.6%), pain (12.9%), nausea/vomiting (10.8%), dizziness/iightheadedness (8.8%), and bieeding/spotting (6.8%). Hypervoiemia occurred in <1% of cases. During the first year of reiiance on the Essure micro-inserts for contraception (approximately 15 months after micro-insert piacement). the foiiowing episodes were reported as at ieast possibly reiated to the fssuremicro-inserts: back pain (9.0%), abdominai pain (3.8%), dyspareunia (3.6%). Aii other events occurred in iess than 3% of women. PATIENT INFORfHATION: Please see Patient Information Booklet. PHYSICIAN INFORMATION: For complete prescribing information physicians should refer to the Cssure System Instructions for Use. Oonceptus Incorporated 331 East Eveiyn Avenue, Mountain View, CA 94041 USA •Trademark of ETHiCON, INC. CC-0366 08Sep05F CO UJ O < o o Control and Prevention’s Healthy People 2010^^ recommend between 30 to 90 minutes of daily moderate physical activity, and that this activity be done at least 5 days a week—or even 7 days per week—depending on whether a person’s goal is weight maintenance or weight loss. Another option, offered by the CDC, is that people do 20 minutes of vigorous activity 3 days or more per week. All of the groups recommend staying within caloric intake requirements (TABLE). • References 1. Miller we , Koceja DM, Hamilton EJ. A meta-analysis of the past 25 years of weight loss research using diet, exercise or diet plus exercise intervention. IntJ Obes 1997; 21:941-947. 2. Skender M, Goodrick G, Del Junco D. Comparison of 2 year weight loss trends in behavioral treatments of obesity: Diet, Exercise, and Combination interventions. JAmer DietAssoc 1996; 96:342-346. 3. Ross R, Freeman JA, Janssen I. Exercise alone is an effective strategy for reducing obesity and related comorbidities. Exerc Sport Sci Rev 2000; 28:165-170. 4. Tsai A, Sandretto A, Chung Y Dieting is more effective in reducing weight but exercise is more effective in reducing fat during the early phase of a weight-reducing program in healthy humans. J Nut Biochem 2003; 14:541-549. 5. Curioni C, Lourenco P. Long-term weight loss after diet and exercise: a systematic review. Internat J
Obes 2005; 29:1168-1174. 6. Jakicic J, Marcus B, Gallagher K, Napolitano M, Lang W. Effect of exercise duration and intensity on weight loss in overweight, sedentary women, a randomized trial. JAMA 2003; 290:1323-1330. 7. Jakicic J, Winters C. Lang W, Wing R. Effects of intermittent exercise and use of home exercise equipment on adherence, weight loss, and fitness in overweight women- a randomized trial. JAMA 1999; 282:1554-1560. 8. Schmidt W, Biwer C, Kalscheuer L. Effects of long versus short bout exercise on fitness and weight loss in overweight females. J Am Coll Nutr 2001; 20:494-501. 9. Jeffrey RW, Wing RR, Sherwood NE, Tate DF. Physical activity and weight loss: does prescribing higher physical activity goals improve outcome? Am J Clin Nutr 2003; 78:684-689. 10. National Institutes of Health, National Heart, Lung, and Blood Institute. Ciinicai Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report. Obes Res 1998; 6:6-26. 11. Department of Health and Human Services. Dietary guidelines for Americans 2005 [Internet monograph]. Washington, DC: Department of Health and Human Services; 2005. Available at: www.health.gov/dietaryguideIines/dga2005/document/html/chapter4.htm. Accessed on September 4, 2007. 12. Healthy People 2010 [Web site]. Rockville, Md: Office of Disease Prevention and Health Promotion, US Department of Health and Human Services; 2002. Available at: www.healthypeople.gov/document/html/volume2/ 22physical.htm. Accessed on September 4, 2007.ISSN 2304-3415, Russian Open Medical Journal 2012; 1: 0308 1 Preventive medicine © 2012, LLC Science and Innovations, Saratov, Russia www.romj.org Original article Do different groups have different risk factors for dieting and exercise as body management strategies? Behshid Garrusi, Mohammad Reza Baneshi, Fatemeh Amiri Kerman University of Medical Sciences, Kerman, Iran Received 17 October 2012, Revised 27 Oct 2012, Accepted 31 Oct 2012. © 2012, Garrusi B., Baneshi M.R., Amiri F. © 2012, Russian Open Medical Journal Abstract: Aim – Body change strategies are activities that could be potentially harmful. Individuals may use different methods for achieving advertised ideal body. Some of demographic and psychosocial contributing factors could be affect decision regarding body management activities. In Iran there is a few research about this matter, therefore the aim of this study was exploring risk factors in body management. Materials and Methods – In this cross sectional study, 400 people participated that including general population, university students and body building clubs attainders. The self administrated questionnaire based on reliable sources of body image that evaluated its validity and validity. Statistical analysis was done by using central indexes and distribution and logistic regression. Data analysis was done by software of SPSS 16. Results – Marital status, education, economic status, age and BMI had no relation with body management strategies. Birthplace effects on choose of diet and exercise. Gender is only had effect on exercise choosing. Use of Western TV had effect on doing exercise. Pressure of relatives was an important factor in decision about dieting. Self steam and compare of appearance with others affected choosing of dieting. There were no differences between selected groups. Conclusion – In spite of similarities between body dissatisfaction and its management strategies with other studies in Iran, there is necessity for future studies. Keywords: dieting, exercise, body image, Iran. Cite as Garrusi B, Baneshi MR, Amiri F. Do different groups have different risk factors for dieting and exercise as body management strategies? Russian Open Medical Journal 2012; 1: 0308. Correspondence to Behshid Garrusi. Address: Department of Community Medicine, Afzallipour Medical School, Kerman University of Medical Sciences, Kerman, Iran(IR). Tel: +98‐341‐3224613. Fax: +98‐341‐3221671. E‐mail: bgarrusi@kmu.ac.ir, behshidgarrusi@gmail.com. Introduction While concerns about one’s body and degree of physical attractiveness have been a part of history, these concerns have become more intense in recent decades. Body image has been defined as the perception of overall physic cal appearance .It consider a multidimensional issue that includes perception, attitude, feeling and the effects of these perceptions on the individual’s behaviors [1] Body size estimation, attractiveness and one’s feelings about these are among the aspects of body image [1]. Body image is the mental representation about own body. Body satisfaction and its related problems were, in the past, known as a western culture phenomenon; however, recent studies are finding that it is now a worldwide matter. Despite previous beliefs, body concerns and eating disorders are increasing in Asian countries, and in some of these societies, their prevalence is similar to that of western cultures [2, 3]. In recent decades, the emphasis for the ideal women has been on thinness, while the emphasis for the ideal man has been on muscledevelopment/masculinity [4]. These body characteristics are considered symbols of success, self control and sexual attractiveness in women and empowerment in men [1, 4]. There are multiple differences between Asian cultures that can affect an individual’s perceptions, attitudes and behaviors [5]. For example, in east Asia, Japanese women suffer more from eating disorders and body dissatisfaction than Taiwanese women [6]. Researchers contend that there are many cultural differences within east Asian countries [7] as well as significant differences between eastern and western Asian cultures. Body image and body satisfaction can be affected by many socio‐cultural factors [8, 9]. Culture plays a significant role in the conceptualization of beauty and attractiveness [8]. Desire for achieving of Ideal body, could be cause some of health consequences ,such as eating disorders and unhealthy behaviors for body change. Body dissatisfaction is correlated with various attempts to change one’s body, and these efforts can begin in children as young as 5‐years‐old [10, 11]. The most accepted method is dieting, a method that can result inanorexia, if successful and encouraged by others,orbulimia, which hascompensatory activities such as induced vomiting and theuse of laxatives [12]. As previously stated, females wish to be thinner, and males wish to be more masculine [10]. These desires can cause males to exercise excessively and engage in steroid use,whilefemalesprefer dieting strategies or surgery. In somestudies,however,body image dissatisfaction negatively correlated with physical activity, especially among adolescent girls [10]. The aim of this identifying of body change strategies that were chosen by different groups in one Iranian sample. [ ISSN 2304-3415, Russian Open Medical Journal 2012; 1: 0308 2 Preventive medicine © 2012, LLC Science and Innovations, Saratov, Russia www.romj.org Material and Methods This population‐based study was carried out in Kerman, the capital of the largest province in Iran. The main outcomes of the study include body change strategies. We focused on two main methods: diet (restricted food, induced vomiting) and exercise (heavy exercise for masculinity or weight reduction). In this study, was done in three different group, general population, university students and body building (gym) users. These participants were selected) by multistage sampling. Self‐administrated questionnaire include below parts: Demographic variables: Age (>20, <20 years), gender (male, female), economical status (fair to medium and good to excellent), marital status (married, single), place of birth (big cities, small cities and village), BMI (cut‐offs at 18.5, 24.9, and 29.9, subjects were categorised into four groups: BMI<18.5 (thin), BMI=18.5‐24.9 (normal), BMI=25‐29.9 (overweight), BMI>30 (obese), use of media (TV, fashion magazine). Socio‐cultural variables: This parts evaluated comparison of body with others {Physical Appearan
ce Comparison Scale (PACS)}, that had acceptable reliability and validity in Persian [13], perceived pressure from relatives {Perceived Socio‐cultural Pressure Scale (PSPS)}, Body Satisfaction (Figure Rating Scale ) that subjects were classified into three groups: no body dissatisfaction their current and ideal shapes were the same), mild dissatisfaction (BD score of 1), and severe dissatisfaction (the difference was greater than 1), and Self Steam {Rosenberg self steam scale (RES)}. This study was approved by Ethical Committee of Kerman Medical Sciences University. Statistical analysis Descriptive statistics were used to summarise the data. A series of multifactorial logistic regression models were applied to identify the factors that influence each of the outcomes or body management methods (i.e., diet, exercise). The results are presented in terms of the odds ratio (OR), associated 95%‐ confidence intervals (CI), and P‐value. In addition, the probability of outcomes was estimated from developed logistic models. The estimated probabilities were then compared with the observed individual’s status to calculate the correct classification proportion. P<0.05 was considered as significant. Results About 48.5% (149) of 400 respondents were female. The mean (SD) for age in three groups (general population, university students, gym users) were 27.6 (8.36), 23.13 (3.29), 22.09 (2.19) years, respectively. Some of demographic characteristics of respondents were shown in Table 1. Mean of BMI in three groups were 23.75 (4.12), 49 (3.5), 22.90 (2.96) kg/m2 inprevious groups (Table 1). Frequencies of Body Dissatisfaction categories in participants were listed in Table 2. Regarding the factors that encourage people to manage their body shape through dieting, we find that pressure from relatives (PSPS) (CI 95%: 0.83‐0.95, P=0.01, own comparison with others (PACS) (CI 95%: 1.01‐1.16, P=0.029), self steam (CI 95%: 1.01‐1.38, P=0.029) where are all influencing variables (Table 3). Belonging to specific group, and gender, there were no effect for decision regarding choose of body image strategies. With respect to exercise, we find that gender (CI 95%: 0.19‐ 0.68, P<0.001) and use of western TV (CI 95%: 1.16‐3.92, P=0.014), were important factors. It shows that other factors such as scores of PACS, and PSPS or other socio‐cultural variables, there were not influencing factors. Choosing of body management strategies had not affect by belonging to special groups. Place of birth had significant effect on dieting (CI 95%: 1.35‐ 13.01, P=0.013) and exercise (CI 95%: 0.12‐0.80, P=0.016). Participants who were born in big cities were 4.1 times more likely to manage their body shape through dieting. Born in big cities was increased chance of using exercise as a body change strategies about 30% (Table 4). Table 1. Demographic characteristics of respondents Variable Level Frequency Percent Age <20 85 21.2 >20 315 78.8 Gender Female 194 48.5 Male 206 51.5 Marital status Single 279 69.8 Married 121 30.2 Education University degree 73 18.2 High school or lower 327 81.8 Economic Status Fair‐medium 246 61.5 Good‐excellent 154 38.5 Table 2. Distribution of body dissatisfaction General population University Students Gym users Body Mild BD 14.3% 17.8% 8.0% Dissatisfaction (BD) Severe BD 6.8% 9.5% 3.5% BD=Body Dissatisfaction Table 3. Identification of factors that encourage people to diet as a way to manage their body shape through a multi factorial logistic regression Variable OR CI 95% P‐level Age 0.50 0.39‐1.47 0.407 Gender 1.03 0.59‐1.79 0.931 Education 0.93 0.46‐1.90 0.85 Marital status 0.61 0.33‐1.10 0.102 Place of Birth 4.19 1.35‐13.01 0.013 Economic Status 1.74 1.0‐3.04 0.05 Western TV 0.66 0.39‐1.11 0.118 Study Group: ‐ Body building (gym )users ‐ University students 1.66 1.16 0.77‐3.61 0.61‐2.19 0.197 0.652 PSPS (Perceived Socio‐Cultural Pressure Scale) 0.89 0.83‐0.95 0.01 PACS (Physical Appearance Comparison Scale) 1.08 1.01‐1.16 0.029 BMI (Body Mass Index) 0.97 0.91‐1.05 0.474 Body Dissatisfaction (BD): ‐ Mild BD ‐ Severe BD 0.60 1.151.38 0.34‐1.06 0.53‐2.50 0.081 0.727 RES (Rosenberg Self Steam) 1.38 1.01‐1.38 0.029 ISSN 2304-3415, Russian Open Medical Journal 2012; 1: 0308 3 Preventive medicine [ © 2012, LLC Science and Innovations, Saratov, Russia www.romj.org Table 4. Identification of factors that encourage people to exercise as a way to manage their body shape through a multi factorial logistic regression Variable OR CI 95% P‐level Age 0.95 0.48‐1.90 0.888 Gender 0.36 0.19‐0.68 0.001 Education 0.54 0.23‐1.26 0.155 Marital status 2.09 1.01‐4.32 0.48 Place of Birth 0.30 0.12‐0.80 0.016 Economic Status 1.01 0.55‐1.40 0.979 Western TV 2.13 1.16‐3.92 0.014 Study Group: ‐ Body building (gym )users ‐ University students 1.30 1.49 0.53‐3.19 0.74‐2.99 0.563 0.261 PSPS (Perceived Socio‐Cultural Pressure Scale) 1.04 0.96‐1.12 0.34 PACS (Physical Appearance Comparison Scale) 1.00 0.93‐1.08 0.953 BMI (Body Mass Index) 0.97 0.90‐1.05 0.479 Body Dissatisfaction (BD): ‐ Mild BD ‐ Severe BD 0.78 0.81 0.41‐1.46 0.36‐1.84 0.436 0.62 RES (Rosenberg Self Steam) 1.14 0.97‐1.35 0.124 Discussion Among contributing factors that could be affect decision about body change activities, body dissatisfaction is considered as an important factors. Body dissatisfaction is known significant predictors of body change activities for women [14]. The desire for thinness as an appearance‐related reason for exercise is associated with body dissatisfaction and low self‐esteem. In some studies, however, body image dissatisfaction negatively correlated with physical activity, especially among adolescent girls [15]. Some studies found that body satisfaction in women has a greater effect on self‐esteem than in men. Chronic dieters have increased body dissatisfaction and lower self‐esteem [16]. It was surprising that in recent study, body dissatisfaction had no effect on body management strategies. Body image and body satisfaction can be affected by many socio‐cultural factors [8], that may be a greater role in body change activities. Although this effect on dieting was evident in both genders, dieting was more prominent in males [17]. However, according previous studies, we found that self‐ esteem had contributing effect on body change activities especially in dieting. Socio‐cultural variables are important factors that contribute to body dissatisfaction and related problems such as desire for body management strategies. One of the socio‐cultural factors that may affect an individual’s desire to be thin or masculine and a person’s decision regarding body change strategies is perceived pressure from family, friends and/or the media [8]. One of the social groups for comparison is the peer group. Peer groups have a significant effect on body satisfaction and body change activities. The effect of peers with ideal body types was associated with longer periods of exercise, especially for women. Although this comparison appears higher in females, peer effect on body satisfaction and decisions about body changes are found in both genders [4]. In our study, dieting was influenced by comparison with others and family and peer pressures. Body image is affected by environment and cultural issues. In big cities, individuals are more prone to media or social pressure such as fashion, magazines, beauty contest. In addition, in big cities, social situations and marriage could be related to attractive appearance [18]. Ideal body image is promoted through the media that suggests thinness is the sign of attractiveness. Despite the desire to increase muscle mass, weight concerns and dieting are also important for males [19]. Although heavy exercise was done for weight loss achievement of masculinity especially for male adolescents. Effects of born in big cities and western TV. On body management strategies were shown in recent study. Such as previous researches, gender could be an important factor for decision about body
management. Belonging to specific group, there was no effect on body management activity. The reason of this finding may be due to greater power of other contributing factors such as pressure from relatives, friends and media. Based on this studies` results, body management strategies in different cultures were different. Conclusion Body image and related consequences such as body change activities are new issues in Iran. It seem socio‐cultural factors are important predictive factors for body change activities .White considering differences between Asian culture ,in planning for harm reduction of unhealthy behavior in dieting or exercise , culture must be consider seriously. Future Asian transcultural studies about these differences are advised. Acknowledgement: This research was financially supported by Neurosciences Research Center of Kerman University of Medical Sciences. Conflict of interest: none declared. Reference 1. Tiggemann M. Body image across the adult life span: Stability and change. Body Image 2004; 1: 29‐41 (PMID: 18089139). 2. Xu X, Mellor D, Kiehne M, Ricciardelli LA, McCabe MP, XuY. Body dissatisfaction, engagement in body change behaviors and sociocultural influences on body image among Chinese adolescents. Body Image 2010; 7(2): 156‐164 (PMID: 20089467). 3. Lee AM, Lee S. Disordered eating in three communities of China: A comparative study of female high school students in Hong Kong, Shenzhen and rural Hunan. Int J Eat Disord 2000; 27: 317‐327 (PMID: 10694718) 4. Ricciardelli LA, McCabe MP. A biopsychosocial model of disordered eating and the pursuit of muscularity in adolescent boys. Psychol Bull 2004; 130: 179‐205 (PMID: 14979769). 5. Yates A, Edman J, Aruguete M. Ethnic differences in BMI and body/self‐dissatisfaction among Whites, Asian subgroups, Pacific Islanders, and African‐Americans. Jour Adolesc Health 2004; 34(4): 300‐307 (PMID: 15040999). 6. Shih M, Kubo C. Body shape preference and body satisfaction in Taiwanese college students. Psychia Resear 2002; 111: 215‐228 (doi: 10.1016/S0165‐1781(02)00138‐5). 7. Ryu HR, Lyle RM, McCabe GP. Factors associated with weight concerns and unhealthy eating patterns among young Korean females. Eat Disord 2003; 11: 129‐141 (PMID: 16864515). 8. Jackson T, Chen H. Sociocultural predictors of physical appearance concerns among adolescent girls and young women from China. Sex Roles 2008; 58: 402‐411 (doi: 10.1007/s11199‐007‐9342‐x). 9. Stice E. Review of the evidence for a socio‐cultural model of bulimia nervosa and exploration of the mechanisms of action. Clin Psychol Rev 1994; 14: 633‐661 (doi: 10.1016/0272‐7358(94)90002‐7). ISSN 2304-3415, Russian Open Medical Journal 2012; 1: 0308 4 Preventive medicine © 2012, LLC Science and Innovations, Saratov, Russia www.romj.org 10. McCabe MP, Ricciardelli LA. Sociocultural influences on body image and body changes among adolescent boys and girls. J Soc Psychol 2003; 143(1): 5‐26 (PMID: 12617344). 11. Davison KK, Markey CN, Birch LL. Etiology of body dissatisfaction and weight concerns among 5‐year‐old girls. Appetite 2000; 35: 143‐151 (PMID: 10986107). 12. Stice E, Hayward C, Cameron R, Killen JD, Taylor CB. Body image and eating related factors predict onset of depression in female adolescents: a longitudinal study. J Abnorm Psychology 2000; 109: 438‐444 (PMID: 11016113). 13. Garrusi B, Garousi S ,Baneshi MR. Body image and body change: predictive factors in an Iranian. IJPM 2012 [In press]. 14. Cachelin FM, Veisel C, Barzegarnazari E, Streigel‐Moore RH. Disordered eating, acculturation, and treatment seeking in a community sample of Hispanic, Asian, Black, and White women. Psychol Women Q 2000; 24: 244‐253 (doi: 10.1111/j.1471‐6402.2000.tb00206.x). 15. Neumark‐Sztainer D, Wal M, Eisenberg ME, Story M. Obesity and eating disorders in older adolescents: Does early dieting make things better or worse? J Adolesc Health 2005; 36: 152‐153 (doi: 10.1016/j.jada.2006.01.003). 16. Gingras J, Fitzpatric J, Mccargar L. Body Image of Chronic Dieters: Lowered Appearance Evaluation and Body Satisfaction. J Am Diet Assoc 2004; 104: 1589‐1592 (doi: 10.1016/j.jada.2004.07.025). 17. Friestad C, Rise J. A longitudinal study of the relationship between body image, self esteem and dieting among 15‐21 year olds in Norway. Eur Eat Disord Rev 2004; 12: 247‐255 (doi: 10.1002/erv.570). 18. Hasmukh SH, WasimSH , Singh S. Are Indian Adolescents girl students more conscious about their body image than their colleague boys? National Journal of Community Medicine 2012; 3(2): 344‐347. 19. Hargreaves D, Tiggemann M. The effect of ‘thin ideal’ television commercials on body dissatisfaction and schema activation during early adolescence. J Youth Adolesc 2003; 32: 367‐373 (doi: 10.1023/A:1024974015581). Authors: Behshid Garrusi – MD, Associate Professor of Psychiatry, Neuroscience research center, Department of community medicine, Afzallipour Medical School, Kerman University of Medical Sciences, Kerman, Iran; Mohammad Reza Baneshi – PhD, Assistant Professor of Statistics, Research Center For Modeling in Health, Kerman University of Medical Sciences, Kerman, Iran; Fatemeh Amiri – MD, Student Research Center, Kerman University of Medical Sciences, Kerman, Iran. Copyright of Russian Open Medical Journal is the property of Science & Innovations LLC and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder’s express written permission. However, users may print, download, or email articles for individual use.OBESITY AND THE DIGESTIVE SYSTEM Diet and exercise in management of obesity and overweight Kwong Ming Fock* and Joan Khoo† Departments of *Gastroenterology and † Endocrinology, Changi General Hospital, Singapore Keywords BMI, diet, exercise, NAFLD, obesity. Accepted for publication 30 September 2013. Correspondence Professor Kwong Ming Fock, Division of Gastroenterology, Department of Medicine, Changi General Hospital, 2 Simei Street 3, Singapore 529889. Email: kwong_ming_fock@cgh.com.sg Abstract According to World Health Organization, in 2010 there were over 1 billion overweight adults worldwide with 400 million adults who were obese. Obesity is a major risk factor for diabetes, cardiovascular disease, musculoskeletal disorders, obstructive sleep apnea, and cancers (prostate, colorectal, endometrial, and breast). Obese people may present to the gastroenterologists with gastroesophageal reflux, non-alcoholic fatty liver, and gallstones. It is important, therefore, to recognize and treat obesity. The main cause of obesity is an imbalance between calories consumed and calories expended, although in a small number of cases, genetics and diseases such as hypothyroidism, Cushing’s disease, depression, and use of medications such as antidepressants and anticonvulsants are responsible for fat accumulation in the body. The main treatment for obesity is dieting, augmented by physical exercise and supported by cognitive behavioral therapy. Calorie-restriction strategies are one of the most common dietary plans. Low-calorie diet refers to a diet with a total dietary calorie intake of 800–1500, while very low-calorie diet has less than 800 calories daily. These dietary regimes need to be balanced in macronutrients, vitamins, and minerals. Fifty-five percent of the dietary calories should come from carbohydrates, 10% from proteins, and 30% from fats, of which 10% of total fat consist of saturated fats. After reaching the desired body weight, the amount of dietary calories consumed can be increased gradually to maintain a balance between calories consumed and calories expended. Regular physical exercise enhances the efficiency of diet through increase in the satiating efficiency of a fixed meal, and is useful for maintaining diet-induced weight loss. A meta-analysis by Franz found that by calorie restriction and exercise, weight loss of 5–8.5 kg was observed 6 months after intervention. After 48 months, a mean of 3–6 kg was maintained. In conclusion, there is e
vidence that obesity is preventable and treatable. Dieting and physical exercise can produce weight loss that can be maintained. Introduction Since 1980, obesity has more than doubled globally and is now considered as a major health hazard and a global epidemic. This review aims to evaluate the current management of obesity and overweight employing a combination of dietary interventions, exercise, and behavioral modification. For some patients, pharmacological therapy or bariatric surgery is required. Definition of obesity Obesity can be defined as an excessive amount of fat that increases the risk of medical illness and premature death. A simple and convenient way of defining obesity and overweight led by the World Health Organization (WHO) and the National Institute of Health (NIH) is based on body mass index (BMI). BMI is derived by dividing one’s weight in kilograms by the square of one’s height in meters. Classification of overweight and obesity is based on data gathered from population-based epidemiology studies that evaluated the relationship between obesity and rates of mortality and morbidity that are adiposity related. A BMI (kg/m2 ) between 25 and 29.9 is deemed to be overweight. Obesity is defined as BMI ≥ 30 and is further subdivided into Class I–III. There is some evidence to suggest that risks of adiposity-related complications occur at lower BMIs in Asians. Hence, China1 used a BMI of 28 for obesity and Japan2 used a BMI cut-off of 25 kg/m2 for cut-off. The WHO has recommended that BMI > 27.5 kg/m2 be used as a cutoff for Asians, taking into consideration the increased cardiovascular risk at the BMI. Health consequences of obesity Mortality. On average, obesity reduces life expectancy by 6 to 7 years:3 a BMI of 30–35 reduces life expectancy by 2–4 years while severe obesity (BMI > 40) reduces life expectancy by 10 years.4 doi:10.1111/jgh.12407 bs_bs_banner Journal of Gastroenterology and Hepatology 2013; 28 (Suppl. 4): 59–63 59 © 2013 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd Morbidity. Complications of obesity are either directly caused by obesity or indirectly related through mechanisms sharing a common cause such as a sedentary life style or poor diet. The strongest link is with type 2 diabetics. Obesity accounts for 64% of cases of diabetics in men and 79% of cases in women. Other diseases attributable to obesity are cardiovascular disease— hypertension, stroke, coronary artery disease, venous stasis deep vein thrombosis, osteoarthritis, gastrointestinal disease, gastroesophageal reflux disease, cholelithiasis, non-alcoholic fatty liver disease (NAFLD), endometrial breast cancer, and colorectal cancer. Obesity is the leading cause of cancer just behind smoking. Metabolic disorders include metabolic syndrome, prediabetic state, hyperlipidemia, and polycystic ovary syndrome. Most patients with obstructive sleep apnea (OSA) are obese, although in lean persons, other factors such as cephalometric defects contributed to risk of OSA. In addition to BMI and waist circumference, it is important to look out for comorbidities that are associated with obesity such as diabetes, NAFLD, polycystic ovary syndrome, OSA, and osteoarthritis. Clinical evaluation of obesity in adults: waist circumference Central or truncal obesity, as measured by waist circumference, is also associated with increased risk for heart disease, diabetes mellitus, hypertension, and hyperlipidemia.5 The WHO STEPwise approach to surveillance protocol for measuring waist circumference requires waist circumference to be measured at the midpoint between the lower margin of the palpable rib and the top of the iliac crest.6 The NIH, which provided the protocol for use in the National Health and National Examination Survey, determines that waist circumference be measured at the top of the iliac crest. Ethnic differences exist, and in Asia, waist circumference > 80 cm for females and > 90 cm for men are considered outside the normal range.7 Establishing the cause of overweight and obesity Although excessive food energy intake and a sedentary lifestyle account for most cases of overweight and obesity, it is important to recognize that medical illness and drug treatment of medical illness can increase the risk of obesity and are amenable to treatment. The neuroendocrine causes of obesity include hypothyroidism, Cushing’s syndrome, growth hormone deficiency, hypogonadism, and polycystic ovary syndrome. Eating disorders, notably binge eating disorders and night eating syndrome, also give rise to obesity. Obesity is not regarded as a psychiatric disorder, but the risk of obesity is increased in patients with psychiatric disorders such as depression. Medications that can cause weight gain include antidepressants, antidiabetic drugs, anticonvulsants, antipsychotic medication, beta-blockers, and steroid hormones. Cessation of smoking is associated with weight gain. It is important to note comorbidities associated with obesity: diabetes mellitus, hyperlipidemia, hypertension, and cardiovascular disease. Medical treatment of overweight and obesity The management of overweight and obesity is lifestyle intervention, consisting of dietary intervention, exercise, and behavioral treatment. Setting a goal for weight loss Setting a goal for weight loss is the first step in planning a weight loss program. The patient needs to accept that the goal is reasonable, realistic, and attainable. An initial weight loss of 5–7% of bodyweight within 6 months is achievable. The Diabetes Prevention Program is an example of a successful lifestyle intervention program that set the weight loss target of 7% of bodyweight.8 Dietary intervention Dietary intervention is the cornerstone of weight loss therapy. Most of the dietary regimens proposed for weight loss focus on energy content and macronutrient composition. It is the energy content that determines the efficiency of the dietary regimens. Obesity treatment guidelines issued by the NIH recommend that persons who are overweight or who have class I obesity and who have two or more risk factors should reduce their energy intake by 500 kcal/day.9 Persons with class II and class III obesity should strive for 500–1000 kcal/day reduction. With a reduction of 500 kcal/day energy intake, a weight reduction of 0.5 kg/week can be achieved. To provide a diet that results in the desired energy deficit, it is necessary to determine the patient’s daily energy requirement, which can be estimated by using the Harris–Benedict equation10 or the WHO equation11 or American Gastroenterological Association dietary guidelines.12 Type of diets In general, there are four types of dietary regimens used in the treatment of the overweight or obese persons: (Table 1) 1 Low-calorie diet (LCD) 2 Low-fat diet 3 Low-carbohydrate diet 4 Very low-calorie diet (VLCD) The first three diets are 800–1500 kcal/day while VLCD is < 800 kcal/day. LCD. LCDs are high in carbohydrate (55–60%), low in fat (less than 30% of energy intake), and high in fiber and have a lowglycemic index. Alcohol and energy-dense snacks should be avoided. LCD has been shown in 34 randomized trials to reduce body weight by 8% during 3–12-month period.13 Overweight or obese patients tend to underestimate their energy intake. To help them overcome this, portion-controlled or prepackaged meals that make up the required energy intake are available. Replacement meals are available as drinks, nutrition bars, or prepackaged meals. A 4-year study demonstrated weight loss improvement in blood sugar and blood pressure for persons taking meal replacement diets.14 Diet and exercise for weight management KM Fock and J Khoo 60 Journal of Gastroenterology and Hepatology 2013; 28 (Suppl. 4): 59–63 © 2013 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd Low-fat diets. These diets reduce the daily intake of fat to 20–25% of total energy intake. For a person on a 1500-calorie diet, this translates to 30–37 g of fat, which can be counted using food label from packages. Alternatively, a dietician c
an provide the person with a specific menu plan that has reduced fat. According to a meta-analysis of 16 trials, low-fat diet used over 2–12 months resulted in mean weight loss of 3.2 kg and improved cardiovascular risk factors (Table 1).15 Low-carbohydrate diet. The carbohydrate content of the diet is an important determinant of short-term (less than 2 weeks) weight loss. Low-carbohydrate (60–150 g of carbohydrate/day) and very low-carbohydrate diet (0 to < 60 g) have been popular for many years. Glycogen utilization occurs when carbohydrate intake is restricted. When the carbohydrate intake is less than 50 g/day, ketosis will develop from glycogenolysis, resulting in fluid loss. Many of the current low-carbohydrate diets (e.g. Atkins diet) limit carbohydrate intake to 20 g/day but allow unrestricted amounts of fat and protein. A meta-analysis of five trials found that weight loss at 6 months favoring low-carbohydrate over low-fat diet is not sustained at 12 months.16 Triglycerides and high-density lipoprotein (HDL) cholesterol changed more favorably in people assigned to low-fat diet. There are data from the National Health Study and Health Professional, Follow Up study that low-carbohydrate diet with the highest decile for animal protein and fat were associated with higher all-cause and cardiovascular mortality.17 VLCD. VLCDs are diets with energy content of 200–800 kcal/ day. Diets below 200 kcal/day are starvation diets. VLCDs are not recommended for general use, as there are significant adverse events such as electrolyte unbalance, low blood pressure, and increased risk of gallstones. Its use needs to be supervised by trained medical personnel. Each of the four types of diet for weight loss has its proponents. In a meta-analysis of 80 weight loss studies, mean weight loss of 5 to 8.5 kg (5–9%) was observed during the first 6 months from interventions involving a reduced-energy diet and/or weight loss medications with weight plateaus at approximately 6 months, with maintenance of 3 to 6 kg (3–6%) of weight loss at 48 months.18 A randomized controlled trial comparing four weight loss diets with different compositions of fat, carbohydrate and protein found no difference in outcomes, with a 2- to 4-kg weight loss with all diets after a year.19 After 2 years, all calorie-restricted diets result in equal weight loss irrespective of the macronutrient composition.19 In contrast, all studies found that dietary adherence is an important determinant of weight loss.13–19 Thus, choosing a diet with a macronutrient composition based on a subject’s taste preference can achieve better compliance. Exercise and obesity Physical activity alone is not an effective method for achieving initial weight loss, although most overweight or obese people tend to choose exercise as the first interventional option. Without calorie restriction, weight loss through exercise alone is quite small, about 0.1 kg/week.20 A meta-analysis showed that exercise alone did not result in significant weight loss attempts, although no further weight gain was observed after 12 months.18 Although exercise is not effective for initial weight loss, physical activity is important for maintaining weight loss achieved through dietary intervention. Meta-analyses of 493 studies have shown that people who diet and exercise maintained their weight loss better than those who relied on diet alone.21 Before starting an exercise program, patients should be advised of joint and musculoskeletal injuries as well as cardiovascular risks. The risk of exercise stress testing before an exercise program is controversial. The American College of Cardiology and American Heart Association recommend treadmill for asymptomatic subjects with diabetes mellitus, men older than 45 years of age, and women older than 55 years of age before embarking on an exercise program.22 Other organizations recommend no stress testing for symptomatic subjects undergoing moderate-intensity exercise with guidance in exercise intensity. In our hospital, we use a physical exercise readiness questionnaire for screening purposes. The American College of Sports Medicine recommended in 2009 that moderate-intensity exercising between 150 and 250 min weekly is effective in preventing weight gain. To provide and Table 1 Comparison of different weight-loss diets13–19 Diet Daily caloric content/ composition Mean weight loss Benefits Disadvantages Low calorie 800–1500 kcal 55–60% carbohydrate (high fiber, low GI) < 30% fat ∼ 10% in 3–12 months Reduction in blood glucose, TG, LDL, BP Compliance difficult in long term Low fat 1000–1500 kcal 20–25% fat ∼ 5% in 2–12 months Reduction in blood glucose, LDL, BP Less palatable, feel hungry easily Increase TG Low carbohydrate 1000–1500 kcal 60–150 g of carbohydrate < 60 g (very low carbohydrate) ∼ 5% in 2–12 months Faster initial weight loss than low-fat diets Reduced blood glucose, TG, LDL, BP Ketosis when carbohydrate intake < 50 g/day Very low-calorie diet 200–800 kcal 55–60% carbohydrate (high fiber, low GI) < 30% fat > 10% in 2–8 weeks Rapid weight loss Electrolyte imbalance, hypotension, gallstones Needs medical supervision BP, blood pressure; GI, glycemic index; LDL, serum low-density lipoprotein cholesterol; TG, serum triglyceride. KM Fock and J Khoo Diet and exercise for weight management Journal of Gastroenterology and Hepatology 2013; 28 (Suppl. 4): 59–63 61 © 2013 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd maintain a clinically significant weight loss, at least 200–300 min/ week of moderate-intensity aerobic exercise is required. Resistance training does not enhance weight loss but may increase fat-free mass. Even in the absence of significant weight loss, regular aerobic and resistance exercise improves cardiovascular fitness22 and obesity-related comorbidities such as NAFLD.23 A supervised exercise program involving personal trainers induces and maintains weight loss more effectively than unsupervised physical activity.22 Exercise reduces food intake by increasing the satiating efficiency of a fixed meal.24 NAFLD NAFLD patients are usually overweight or obese and have underlying insulin and or leptin resistance leading to dysfunctional energy metabolism. Weight loss of 10% in overweight NAFLD patients improves liver biochemistry as well as hepatic steatosis and necroinflammation. Lifestyle modification consisting of exercise and diet can help the patients to achieve these goals. A 4–4.5% weight loss can result in 50% reduction in serum alanine aminotransferase, while with exercise alone and no weight loss, signifi- cant improvement in aminotransferase levels can occur, but its effect on liver histology is unknown.23 The American Association for the Study of Liver Diseases, the American College of Gastroenterology, and the American Gastroenterology Association recommend weight loss as the preferred method in management of NAFLD.25 Bariatric surgery Bariatric surgery is defined as gastrointestinal surgery to help severely obese patients lose weight. The US National Institutes of Health’s 2013 guidelines recommended surgery for adults with BMI ≥ 40 kg/m2 without comorbidities or 35 kg/m2 with comorbidities who fail to lose weight by nonsurgical methods,26 and suggested that patients with BMI of 30–34.9 kg/m2 with diabetes or metabolic syndrome may also be offered a bariatric procedure, although current evidence is limited by the lack of longterm data demonstrating net benefit. A recent Asian Consensus Meeting on Metabolic Surgery27 also recommended that the BMI cutoffs be lowered to 35 and 32.5, respectively, and that surgery be considered for Asian adults with BMI ≥ 30 kg/m2 and central obesity (WC > 80 cm in females or > 90 cm in males) and at least two features of metabolic syndrome (raised triglycerides, low HDL cholesterol, hypertension, high-fasting plasma glucose). Gastric banding is a reversible restrictive procedure, while laparoscopic sleeve gastrectomy, Roux-en-Y gastric bypass, and biliopancreatic diversion combine restrictive and malabsorptive
effects that produce 15–35% loss of baseline weight and improve other comorbidities.26 Conclusion Overweight and obesity are increasing at an alarming rate globally and has reached epidemic proportions in almost every country. Obesity has a significant contribution toward cardiovascular diseases, metabolic disorders, gastrointestinal disorders, and cancers. Yet in early stages of weight gain, when a person is overweight, its progression to morbid obesity can be arrested through diet and exercise, without the need for medication, endoscopic, or surgical procedures. We have attempted to put further evidence in support of current best practices in dietary management and exercise. Finally, we conclude with two mnemonics that some of our team members found useful in clinical practice. Factors that contribute to obesogenic state are • Diseases—hypothyroidism, Cushing’s disease • Drugs—corticosteroids, antidepressants, antipsychotics • Diet—intake > activity • Drink—beer, wine, sugar drinks • Decreased—physical activity • Depression and psychosocial An ABCDE approach28 to obesity: A For measurement of cardiovascular risk and comorbidity B For blood pressure control C For cholesterol management D For diet control and text for diabetes E For exercise therapy References 1 Bei-Fan Z, Cooperative Meta-Analysis Group of Working Group on Obesity in China. Predictive values of body mass index and waist circumference for risk factors of certain related diseases in Chinese adults: study on optimal cut-off points of body mass index and waist circumference in Chinese adults. Asia Pac. J. Clin. Nutr. 2002; 11 (Suppl. 8): S685–93. 2 Kanazawa M, Yoshiike N, Osaka T, Numba Y, Zimmet P, Inoue S. Criteria and classification of obesity in Japan and Asia-Oceania. Asia Pac. J. Clin. Nutr. 2002; 11 (Suppl. 8): S132–8. 3 WHO Expert Constitution. Appropriate body mass index for Asian population and its implications for policy and intervention strategies. Lancet 2004; 363: 157–63. 4 Prospective Studies Collaboration, Whitlock G, Lewinoton S et al. Body-mass index and cause-specific mortality in 900 000 adults: collaborative analyses of 57 prospective studies. Lancet 2009; 373: 1083–96. 5 Janssen I, Katzmarzyk PT, Ross R. Waist circumference and not body mass index explains obesity-related health risk. Am. J. Clin. Nutr. 2004; 75: 379–84. 6 Nishida C, Ko GT, Kumanyika S. Body fat distribution and noncommunicable diseases in populations: overview of the 2008 WHO expert consultation on waist circumference and waist-hip ratio. Eur. J. Clin. Nutr. 2010; 64: 2–5. 7 Zimmet K, Alberti KG. Introduction: globalization and the non-communicable disease epidemic. Obesity 2006; 14: 1–3. 8 Diabetes Prevention. Programme (DPP) Research Group. The Diabetes Prevention Program (DPP). Description of lifestyle intervention. Diabetes Care 2002; 25: 2165–71. 9 Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults–the evidence report. National Institutes of Health. Obes. Res. 1998; 6 (Suppl. 2): 51S–209S. 10 Harris JA, Benedict FG. Standard bowel metabolism constants for physiogists and constants in The Carnegie Institute of Washington. A biometric study of basal metabolism in man. Publication 279, Philadelphia, Pennsylvannia: Lippincott 1919. 11 FAO/WHO/UNU. Energy and protein requirements. Report of a joint FAO/WHO/UNU expert consultation. World Health Organ. Tech. Rep. Ser. 1985; 724: 1–206. 12 Klein S, Wadden T, Sugeman HJ. AGA technical review on obesity. Gastroenterology 2002; 123: 882–932. Diet and exercise for weight management KM Fock and J Khoo 62 Journal of Gastroenterology and Hepatology 2013; 28 (Suppl. 4): 59–63 © 2013 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd 13 Strychar I. Diet in the management of weight loss. CMAJ 2006; 174: 56–63. 14 Flechtner-Mors M, Ditschuneit HH, Johnson TD, Suchard MA, Adler G. Metabolic and weight loss effects of long term obesity intervention in obese patients: four-year results. Obes. Res. 2000; 8: 399–402. 15 Astrup A, Ryan L, Grunwald GK et al. The role of dietary fat in body fatness: evidence from a preliminary meta-analysis of ad libitum low-fat dietary intervention studies. Br. J. Nutr. 2000; 83 (Suppl. 1): S25–32. 16 Nordmann AJ, Nordmann A, Briel M et al. Effects of low-carbohydrate vs low-fat diets on weight loss and cardiovascular risk factors: a meta-analysis of randomized controlled trials. Arch. Intern. Med. 2006; 166: 285–93. 17 Fung TT, van Dam RM, Hankinson SE, Stampfer M, Willett WC, Hu FB. Low-carbohydrate diets and all-cause and cause-specific mortality: two cohort studies. Ann. Intern. Med. 2010; 153: 289–98. 18 Franz MJ, VanWormer JJ, Crain AL. Weight-loss outcomes: a systematic review and meta-analysis of weight-loss clinical trials with a minimum 1-year follow-up. J. Am. Diet. Assoc. 2007; 107: 1755–67. 19 Sacks FM, Bray GA, Carey VJ. Comparison of weight-loss diets with different compositions of fat, protein, and carbohydrates. N. Engl. J. Med. 2009; 360: 859–73. 20 Slentz CA, Duscha BD, Johnson JL et al. Effects of the amount of exercise on body weight, body composition, and measures of central obesity: STRIDE—a randomized controlled study. Arch. Intern. Med. 2004; 164: 31–9. 21 Miller WC, Koceja DM, Hamilton EJ. A meta-analysis of the past 25 years of weight loss research using diet, exercise or diet plus exercise intervention. Int. J. Obes. Relat. Metab. Disord. 1997; 21: 941–7. 22 Donelly JE, Blair SN, Jackicic JM. American College of Sports Medicine. ACSM position stand. Appropriate physical activity intervention strategies for weight loss and prevention of weight regain in adults. Med. Sci. Sports Exerc. 2009; 41: 459–71. 23 Harrison SA, Day CP. Benefits of lifestyle modification in NAFLD. GUT 2007; 56: 1760–9. 24 King NA, Caudwell PP, Hopkins M, Stubbs JR, Naslund E, Blundell JE. Dual-process action of exercise on appetite control: increase in orexigenic drive but improvement in meal-induced satiety. Am. J. Clin. Nutr. 2009; 90: 921–7. 25 Chalasani N, Younossi Z, Lavine JE et al. The diagnosis and management of non-alcoholic fatty liver disease: practice guideline by the American Association for the Study of Liver Diseases, American College of Gastroenterology, and the American Gastroenterological Association. Hepatology 2012; 55: 2005–23. 26 Mechanick JI, Youdim A, Jones DB et al. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient—2013 update: cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery. Obesity (Silver Spring) 2013; 21 (Suppl. 1): S1–27. 27 Lakdawala M, Bhasker A, Asian Consensus Meeting on Metabolic Surgery (ACMOMS). Asian Consensus Meeting on Metabolic Surgery. Recommendations for the use of Bariatric and Gastrointestinal Metabolic Surgery for Treatment of Obesity and Type II Diabetes Mellitus in the Asian Population. Obes. Surg. 2010; 20: 929–36. 28 Blaha MJ, Bansal S, Rouf R, Golden SH, Blumenthal RS, AP Defilippis. A practical “ABCDE” approach to the metabolic syndrome. Mayo Clin. Proc. 2008; 83: 932–41. KM Fock and J Khoo Diet and exercise for weight management Journal of Gastroenterology and Hepatology 2013; 28 (Suppl. 4): 59–63 63 © 2013 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd Copyright of Journal of Gastroenterology & Hepatology is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder’s express written permission. However, users may print, download, or email articles for individual use.

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