Fundamentals of Human Nutrition/Weight management

13.3 Weight Management

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Weight Management and Body Image

The concept of weight management is important to keep control of so that the body can achieve and maintain good health. In today’s society, people have created an ideal sense of beauty and body image that is difficult to maintain (Office on Women’s Health, 2009). Women are especially prone to feeling dissatisfied with their body image and feel pressured to stay thin. Comparisons of body weight, family and friend influence, environmental changes, food availability, and doctoral advice all affect body image (Office on Women’s Health, 2009). Various shapes and sizes can form a healthy body, but exercise, rest, and nutritious food items must be part of the daily routine (Physical Activity, 2015).

Introduction

Weight is the essential aspect that people need to stay keenly aware of (Rolfes, Whitney, 14 ed). Weight management is defined as the conservation of a healthy body range by preventing gradual weight gains and weight losses over time (Rolfes, Whitney, 14 ed). Weight management requires constant maintenance, and even with an ideal body weight, good health may not accompany it (Rolfes, Whitney, 14 ed). In order to also have good health, a nutritious diet and high physical activity level must be apparent as well. Weight gains and losses occur at different rates, but do indeed deal with energy balance intake. Strategies to achieve a healthy body weight include realistic goals, proper food intake, good levels of physical activity, an encouraging atmosphere, and optimistic behavior (Rolfes, Whitney, 14 ed). Whether underweight or overweight, health problems can reside.

Weight Loss Strategies To control weight, one must also maintain their eating patterns, physical activity, environment, and psychological mindset. Strategies to control body weight and engage in weight loss are as follows:

1) Realistic Goals: To lose weight, one must understand that in order for a difference to be seen in their body and health, changes need to be made to their lifestyle. It’s not going to be an easy task nor is it going to be quick process. A reasonable weight loss goal and mindset pursuit needs to be set at the beginning of the venture (Food and Nutrition Information Center, 2015).

2) Eating Patterns: Adequate caloric intake is required to provide the body with the proper nutrients and energy for survival (Food and Nutrition Information Center, 2015). Eating breakfast, portion control, slow meal consumption, drinking water, fiber, low dense meals, selective fats, and carbohydrate consumption must be watched carefully. (Library of Medicine, 2015)

3) Physical Activity: Moderate exercise that includes 200 minutes of physical activity a week is essential for the body to lose weight (Rolfes, Whitney, 14 ed). Exercising supports lean muscle tissue, balance, and strength. Physical activity affects the body’s metabolism by speeding it up and suppressing appetite to healthy food intake. Glucose and fatty acids become extremely evident in the blood and also reduces stress (Rolfes, Whitney, 14 ed).

a. According to the 2008 Physical Activity Guidelines for Americans, adults need at least two hours and thirty minutes of moderate-intense aerobic activity every week. Two of these days require muscle-strengthening activities (Physical Activity, 2015). b. Aerobic activities include cardiovascular exercises raise heart rate, cause heavy breathing, and induce sweat.

4) Environmental Influences: The surrounding atmosphere can greatly influence one’s eating patterns. Social interactions cause people to eat more due to the comfort or conversational distractions that interfere with portion control (Rolfes, Whitney, 14 ed). Remember to limit food intake when around various flavors of foods, use small plates, and do not leave food easily accessible after finishing a meal (Food and Nutrition Information Center, 2015).

5) Psychological Mindset: Behavioral patterns need to be practiced and repeated in order for the mind to learn healthy eating and activity factors (Rolfes, Whitney, 14 ed). The cognitive ability to find a problem and treat it with appropriate habits will support a weight loss routine.

Results' The Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics (AAP) assess children up from ages 2 to 19 (Division of Nutrition, BMI, 2015). A Body Mass Index Percentile Calculator is used to measure the body mass index of children, teens, and adults. Although a high BMI can indicate a high amount of body fat, it does not mean that a person is overweight (Division of Nutrition, BMI, 2015). As previously mentioned, various shapes and sizes of bodies are formed due to food consumption, natural body growth, and lifestyle. • Underweight: less than 5% body fat • Normal weight: 5-85% body fat • Overweight: 85-95% body fat • Obese: 95% and over body fat

References

1. Body Image. (2009, September 22). Retrieved December 1, 2015, from http://www.womenshealth.gov/body-image/about-body-image/

2. Physical Activity Basics. (2015, June 4). Retrieved December 1, 2015, from http://www.cdc.gov/physicalactivity/basics/index.htm

3. About Child & Teen BMI. (2015, May 15). Retrieved December 1, 2015, from http://www.cdc.gov/healthyweight/assessing/bmi/childrens_bmi/about_childrens_bmi.html

4. Weight Control: MedlinePlus. (2015, November 10). Retrieved December 1, 2015, from https://www.nlm.nih.gov/medlineplus/weightcontrol.html

5. Interested in Losing Weight? (2015, November 27). Retrieved December 1, 2015, from http://www.nutrition.gov/weight-management/strategies-success/interested-losing-weight

6. Whitney, E., & Rolfes, S. (2015). Understanding Nutrition (Fourteenth ed.).

13.3.1 Underweight

1. Definition
2. Causes
3. Symptoms
4. Problems/complications
5. Treatment

Definition

Being underweight means; weighing less than normal, healthy or required. Having a BMI of ≤18.5 or being less than normal in body weight after adjustment for height, body build & age. 1

Causes

Being underweight can be caused by a variety of factors, including eating disorders like anorexia Nervosa, it can also be linked to certain medical conditions including; hyperthyroidism, cancer, diabetes, psychological problems, inflammatory bowel disease and infections.3 4 Genetics also plays an important role in whether an individual would be underweight or not.5 It may also be a symptom of Malnutrition (a condition that occurs when your body does not get enough nutrients) or Malabsorption (when there is difficulty absorbing nutrients from food). 4

Symptoms

Major symptoms include; Low body weight, BMI of ≤18.5, feelings of fatigue, malaise etc. 3

Problems/Complications

People who are underweight are at risk for health complications, compromised immunity, and may have an increased risk of anemia, heart irregularities, reduced sex hormones, loss of bone density, infertility, hypotension, poor wound healing, low-birth-weight infants( as a result of pre-pregnancy underweight & failure to gain weight during pregnancy), Vulnerability to infections, Loss of Menstruation(Amenorrhea) and osteoporosis. 3 6 7

Prevention & Treatment

In order to avoid or treat being underweight, an overall lifestyle change is necessary. A combination of improved diet, exercise, and appetite stimulants are helpful. 7 8 Exercise helps to keep bones strong & maintain muscle tone, it can also stimulate appetite. Diet should include Nutrient rich food & calorie dense snacks; it should be a diet rich in Fruits, Vegetables, Proteins and Fats from Plant sources. The major focus should be increased intake of healthy calories.8 9 Appetite stimulants like B vitamin supplements can also be used. Eating disorders

13.3.2 Overweight and Obesity

'What Is Obesity?'

Obesity is an excess proportion of total body fat. A person is considered obese when his or her weight is 20% or more above normal weight. The most common measure of obesity is the body mass index or BMI. A person is considered overweight if his or her BMI is between 25 and 29.9; a person is considered obese if his or her BMI is over 30.

"Morbid obesity" means that a person is either 50%-100% over normal weight, more than 100 pounds over normal weight, has a BMI of 40 or higher, or is sufficiently overweight to severely interfere with health or normal function.

Measuring obesity

The most common method of measuring obesity is calculating an individual’s Body Mass Index (BMI). This is calculated by dividing a person’s weight measurement (in kilograms) by the square of their height (in metres).

In adults, a BMI of 25 to 29.9 means that person is considered to be overweight, and a BMI of 30 or above means that person is considered to be obese.

In children and adolescents, BMI varies with age and sex, so the BMI score for children and adolescents is related to the UK 1990 BMI growth reference charts in order to determine a child’s weight status.

BMI is the best way we have to measure the prevalence of obesity at the population level. No specialised equipment is needed and therefore it is easy to measure accurately and consistently across large populations. BMI is also widely used around the world, which enables comparisons between countries, regions and population sub-groups.

For most people, their BMI correlates well with their level of body fat. However, certain factors such as fitness and ethnic origin can sometimes alter the relationship between BMI and body fatness. So then other measurements such as waist circumference and skin fold thickness can also be collected to confirm an individual person’s weight status.

When to Seek Help for Obesity

You should call your doctor if you are having emotional or psychological issues related to your obesity, need help losing weight, or if you fall into either of the following categories.

If your BMI is 30 or greater, you're considered obese. You should talk to your doctor about losing weight since you are at high risk of having health problems. If you have an "apple shape"—a so-called, "potbelly" or "spare tire"—you carry more fat in and around your abdominal organs. Fat deposited primarily around your middle increases your risk of many of the serious conditions associated with obesity. Women's waist measurement should fall below 35 inches. Men's should be less than 40 inches. If you have a large waist circumference, talk to your doctor about how you can lose weight.

10.3.2.1 Global statistics

The prevalence of obesity in England has more than tripled in the last 25 years. The latest Health Survey for England (HSE) data shows that in England in 2010:

• 62.8% of adults (aged 16 or over) were overweight or obese
• 30.3% of children (aged 2–15) were overweight or obese
• 26.1% of all adults and 16% of all children were obese

Foresight’s Tackling Obesities: Future Choices report, published in October 2007, predicted that if no action was taken, 60% of men, 50% of women and 25% of children in Britain would be obese by 2050. Recently reported modelling suggests that without action 41-48% of men and 35-43% of women could be obese by 2030.

10.3.2.2 Causes
Obesity occurs when a person consumes more calories than he or she burns. For many people this boils down to eating too much and exercising too little. But there are other factors that also play a role in obesity. These may include:

Age. As you get older, your body's ability to metabolize food slows down and you do not require as many calories to maintain your weight. This is why people note that they eat the same and do the same activities as they did when they were 20 years old, but at age 40, gain weight.

Gender. Women tend to be more overweight than men. Men have a higher resting metabolic rate (meaning they burn more energy at rest) than women, so men require more calories to maintain their body weight. Additionally, when women become postmenopausal, their metabolic rate decreases. That is partly why many women gain weight after menopause.

Genetics. Obesity (and thinness) tends to run in families. In a study of adults who were adopted as children, researchers found that participating adult weights were closer to their biological parents' weights than their adoptive parents'. The environment provided by the adoptive family apparently had less influence on the development of obesity than the person's genetic makeup. In fact, if your biological mother is heavy as an adult, there is approximately a 75% chance that you will be heavy. If your biological mother is thin, there is also a 75% chance that you will be thin. Nevertheless, people who feel that their genes have doomed them to a lifetime of obesity should take heart. Many people genetically predisposed to obesity do not become obese or are able to lose weight and keep it off.

Environmental factors. Although genes are an important factor in many cases of obesity, a person's environment also plays a significant role. Environmental factors include lifestyle behaviors such as what a person eats and how active he or she is.

Physical activity. Active individuals require more calories than less active ones to maintain their weight. Additionally, physical activity tends to decrease appetite in obese individuals while increasing the body's ability to preferentially metabolize fat as an energy source. Much of the increase in obesity in the last 20 years is thought to have resulted from the decreased level of daily physical activity.

Psychological factors. Psychological factors also influence eating habits and obesity. Many people eat in response to negative emotions such as boredom, sadness, or anger. People who have difficulty with weight management may be facing more emotional and psychological issues; about 30% of people who seek treatment for serious weight problems have difficulties with binge eating. During a binge-eating episode, people eat large amounts of food while feeling they can't control how much they are eating.

Illness. Although not as common as many believe, there are some illnesses that can cause obesity. These include hormone problems such as hypothyroidism (poorly acting thyroid slows metabolism), depression, and some rare diseases of the brain that can lead to overeating.

Medication. Certain drugs, such as steroids and some antidepressants, may cause excessive weight gain.

Health risks
Being obese or overweight brings significant risks at a range of different points throughout life. The health risks for adults are stark. We know that, compared with a healthy weight man, an obese man is:

• five times more likely to develop type 2 diabetes
• three times more likely to develop cancer of the colon
• more than two and a half times more likely to develop high blood pressure – a major risk factor for stroke and heart disease

An obese woman, compared with a healthy weight woman, is:

• almost 13 times more likely to develop type 2 diabetes
• more than four times more likely to develop high blood pressure
• more than three times more likely to have a heart attack

Obesity and overweight pose a major risk for serious diet-related chronic diseases, including type 2 diabetes, cardiovascular disease, hypertension and stroke, and certain forms of cancer. The health consequences range from increased risk of premature death, to serious chronic conditions that reduce the overall quality of life.

For the USA:

• of 22 industrialized countries, the U.S. has the highest obesity statistics
• 2/3 of Americans over age 20 are overweight
• nearly 1/3 of Americans over age 20 are obese

Overweight and obesity lead to adverse metabolic effects on blood pressure, cholesterol, triglycerides and insulin resistance.

The likelihood of developing Type 2 diabetes and hypertension rises steeply with increasing body fatness. Confined to older adults for most of the 20th century, this disease now affects obese children even before puberty. Approximately 85% of people with diabetes are type 2, and of these, 90% are obese or overweight.

Raised BMI also increases the risks of cancer of the breast, colon, prostate, endometroium, kidney and gallbladder.

Chronic overweight and obesity contribute significantly to osteoarthritis, a major cause of disability in adults. Although obesity should be considered a disease in its own right, it is also one of the key risk factors for other chronic diseases together with smoking, high blood pressure and high blood cholesterol.

According to the American Cancer Society, obesity cost an estimated $75 billion in 2003 because of the long and expensive treatment for several of its complications. According to the National Institute of Health, $75-$125 billion is spent on indirect and direct costs due to obesity-related diseases.

Childhood overweight and obesity

Introduction

Children need a healthy, balanced diet that gives them enough energy to grow and develop. This means that children usually need to take in more energy than they use and this extra energy forms new tissues as they grow. However, if children regularly take in too much energy, this is stored as fat and they will put on excess weight. 1

Childhood obesity is one of the most serious public health challenges of the 21st century. The problem is global and is steadily affecting many low- and middle-income countries, particularly in urban settings. The prevalence has increased at an alarming rate. Globally, in 2010 the number of overweight children under the age of five, is estimated to be over 42 million. Close to 35 million of these are living in developing countries.2

Many factors, including genetics, environment, metabolism, lifestyle, and eating habits, are believed to play a role in the development of obesity. However, more than 90% of cases are idiopathic; less than 10% are associated with hormonal or genetic causes.3

Overweight and Obesity

Overweight and obesity are defined as abnormal or excessive fat accumulation that presents a risk to health.2 Operational definitions of obesity in adults are derived from statistical data that analyze the association between body mass and the risk of acute and long-term morbidity and mortality. Because acute medical complications of obesity are less common in children and adolescents than in adults, and because longitudinal data on the relation between childhood weight and adult morbidity and mortality are more difficult to interpret, no single definition of obesity in childhood and adolescence has gained universal approval.

Some investigators have used the terms overweight, obese, and morbidly obese to refer to children and adolescents whose weights exceed those expected for heights by 20%, 50%, and 80-100%, respectively. The body mass index (BMI) has not been consistently used or validated in children younger than 2 years. Because weight varies in a continuous rather than a stepwise fashion, the use of these arbitrary criteria is problematic and may be misleading. 3

A few extra pounds does not suggest obesity. However they may indicate a tendency to gain weight easily and a need for changes in diet and/or exercise. Generally, a child is not considered obese until the weight is at least 10 percent higher than what is recommended for their height and body type. Obesity most commonly begins between the ages of 5 and 6, or during adolescence. Studies have shown that a child who is obese between the ages of 10 and 13 has an 80 percent chance of becoming an obese adult. 4

Measuring overweight and obesity

It is difficult to develop one simple index for the measurement of overweight and obesity in children and adolescents because their bodies undergo a number of physiological changes as they grow. Depending on the age, different methods to measure a body's healthy weight are available.2

Using Body Mass Index (BMI) to Estimate Overweight and Obesity

The BMI is the tool most commonly used to estimate overweight and obesity in children and adults. The BMI is a continuous, although imperfect, measure of body fatness. Calculated as weight (kg) divided by height (m2).The BMI is used because, for most people, it correlates with the amount of fat in their bodies. Children grow at different rates at different times, so it is not always easy to tell if a child is overweight. The BMI correlates closely with total body fat (TBF), which is estimated using dual-energy x-ray absorptiometry (DEXA) scanning in children who are overweight and obese. Normal values for BMI vary with age, sex, and pubertal status, and standard curves representing the 5th through the 95th percentiles for BMI in childhood and adolescence were generated using data from the 1988-1994 NHANES. 35

BMI	Classification
At or above the 85th percentile	Overweight or obese
Overweight or obese	Obese

Special charts, called BMI centile charts, have been developed to show whether children are under or overweight for their age. These charts compare a child’s BMI against other children of the same sex and age.

Tool E4 -This tool contains detailed information on the measurement and assessment of overweight and obesity in children. It provides information on how to measure overweight and obesity using Body Mass Index (BMI) and growth reference charts; provides information on measuring waist circumference; and provides details on how to assess overweight and obesity in children. BMI charts are provided at the end of this tool for girls and boys. This tool is consistent with NICE guidance and also Department of Health recommendations. It is for all healthcare professionals measuring and assessing overweight and obese children.6

Treatment

There are multiple factors that can contribute to a person being overweight or obese. These issues accumulate and worsen over time until an individual is considered overweight or obese. Factors considered when identifying problem areas that could use improvement are:

• Poor diet choices
• Inaccurate food portion sizes
• Lack of moderate physical activity
• Living a sedentary lifestyle

Treatment for a person who is overweight or obese can be a long and difficult journey, and it is extremely important to do so in a manner that is safe and healthy. The most impactful way of succeeding in losing weight in a healthy way is by setting goals, making changes in lifestyle and by doing the process gradually (“How Are Overweight,” 2012).

Pre-packaged meal plans can be a helpful tool for health care professionals to educate a patient about proper portion sizes. Making sure the patient understands the correct amount of which foods they should be eating is critical. Pre-packaged meal plans are also beneficial in assisting the patient later in the process when they are ready to transition back to self-cooked meals and make the long-term commitment to change their lifestyle regarding food. With the support and guidance that the pre-packaged meal plans provide, many individuals can see weight loss results of 50 pounds or greater in around 18–24 weeks (“Physician-Supervised,” 2015).

In addition to being properly educated and monitored regarding eating habits, a patient must also make lifestyle changes with their physical activity. Many overweight or obese people do not partake in much exercise, and a large factor of weight loss and living healthy is physical activity. The patient should be adding physical activity to their daily life by beginning small and gradually increasing as they progress through their weight loss journey. Adding too much exercise too quickly can be problematic, so a gradual approach is more likely to be successful. The staff at Mayo Clinic suggests that the most simple methods of increasing a patient’s activity level is for them to keep moving throughout the day as well as getting around 150–300 minutes of moderate physical activity per week (Mayo Clinic Staff, 2015). Both of these are crucial parts of the behavioral change that can help in treating overweight or obesity. By becoming more active, patients will see progress in their treatment more noticeably than if they remain inactive and continue to live a sedentary lifestyle.

Over an extended amount of time, as the patient progresses through the incremental goals they have set for themselves, they will see greater changes in their physical appearance and health. Once the patient passes the threshold of no longer being considered overweight or obese by a medical professional, the patient’s treatment can be considered complete. They have succeeded in making major alterations to their former lifestyle that will continue to be used to maintain a healthy weight.

References

Mayo Clinic Staff. (2015). Obesity. Retrieved from http://www.mayoclinic.org/diseases-conditions/obesity/basics/treatment/con-20014834

(2012, July 13). How Are Overweight and Obesity Treated? Retrieved from http://www.nhlbi.nih.gov/health/health-topics/topics/obe/treatment

(2015). Physician-Supervised Weight-Loss (Overweight, Obesity and Severe Obesity). Retrieved from http://www.obesityaction.org/obesity-treatments/physician-supervised-programs

Causes for Obesity

The causes of obesity are complex and include genetic, biological, behavioral and cultural factors. Obesity occurs when a person eats more calories than the body burns up. If one parent is obese, there is a 50 percent chance that their children will also be obese. However, when both parents are obese, their children have an 80 percent chance of being obese. Although certain medical disorders can cause obesity, less than 1 percent of all obesity is caused by physical problems. Obesity in childhood and adolescence can be related to:

• poor eating habits
• overeating
• lack of exercise (i.e., couch potato kids)
• family history of obesity
• medical illnesses (endocrine, neurological problems)
• medications (steroids, some psychiatric medications)
• stressful life events or changes (separations, divorce, moves, deaths and abuse)
• family and peer problems
• low self-esteem
• depression or other emotional problems 4

WHO recognizes that the increasing prevalence of childhood obesity results from changes in society. Childhood obesity is mainly associated with unhealthy eating and low levels of physical activity, but the problem is linked not only to children's behaviour but also, increasingly, to social and economic development and policies in the areas of agriculture, transport, urban planning, the environment, food processing, distribution and marketing, as well as education.

The problem is societal and therefore it demands a population-based multisectoral, multi-disciplinary, and culturally relevant approach.

Unlike most adults, children and adolescents cannot choose the environment in which they live or the food they eat. They also have a limited ability to understand the long-term consequences of their behaviour. They therefore require special attention when fighting the obesity epidemic. 2

Consequences of childhood obesity

Health risks now

Childhood obesity can have a harmful effect on the body in a variety of ways. Obese children are more likely to have–

• High blood pressure and high cholesterol, which are risk factors for cardiovascular disease (CVD). In one study, 70% of obese children had at least one CVD risk factor, and 39% had two or more.
• Increased risk of impaired glucose tolerance, insulin resistance and type 2 diabetes.
• Breathing problems, such as sleep apnea, and asthma.
• Joint problems and musculoskeletal discomfort.
• Fatty liver disease, gallstones, and gastro-esophageal reflux (i.e., heartburn).
• Obese children and adolescents have a greater risk of social and psychological problems, such as discrimination and poor self-esteem, which can continue into adulthood.

Health risks later

• Obese children are more likely to become obese adults. Adult obesity is associated with a number of serious health conditions including heart disease, diabetes, and some cancers.
• If children are overweight, obesity in adulthood is likely to be more severe. 7

Prevention of obesity in children

Overweight and obesity, as well as related noncommunicable diseases, are largely preventable. It is recognized that prevention is the most feasible option for curbing the childhood obesity epidemic since current treatment practices are largely aimed at bringing the problem under control rather than effecting a cure. The goal in fighting the childhood obesity epidemic is to achieve an energy balance which can be maintained throughout the individual's life-span.

Note: CC is adding strategies for weight management.

General recommendations

• increase consumption of fruit and vegetables, as well as legumes, whole grains and nuts;
• limit energy intake from total fats and shift fat consumption away from saturated fats to unsaturated fats;
• limit the intake of sugars; and
• be physically active - accumulate at least 60 minutes of regular, moderate- to vigorous-intensity activity each day that is developmentally appropriate.

Societal Recommendations

Curbing the childhood obesity epidemic requires sustained political commitment and the collaboration of many public and private stakeholders.

Governments, International Partners, Civil Society, NGO's and the Private Sector have vital roles to play in shaping healthy environments and making healthier diet options for children and adolescents affordable, and easily accessible. It is therefore WHO's objective to mobilize these partners and engage them in implementing the Global Strategy on Diet, Physical Activity and Health.

WHO supports the designation, the implementation, the monitoring and the leadership of actions. A multisectoral approach is essential for sustained progress: it mobilizes the combined energy, resources and expertise of all global stakeholders involved. 2

Population-based approaches to childhood obesity prevention - The document published by WHO, aims to provide Member States with an overview of the types of childhood obesity prevention interventions that can be undertaken at national, sub-national and local levels. The document first outlines guiding principles for the development of a population-based childhood obesity prevention strategy and then describes the approaches for population-based obesity prevention. There is a broad range of population-level actions that governments can take to prevent childhood obesity. A comprehensive childhood obesity prevention strategy will incorporate aspects of each of the key components. 8

1. http://www.bupa.co.uk/individuals/health-information/directory/o/child-obesity
2. http://www.who.int/dietphysicalactivity/childhood/en/
3. http://emedicine.medscape.com/article/985333-overview
4. http://www.aacap.org/cs/root/facts_for_families/obesity_in_children_and_teens
5. http://win.niddk.nih.gov/statistics/index.htm
6. http://www.fph.org.uk/uploads/HealthyWeight_SectE_Toolkit04.pdf
7. http://www.cdc.gov/obesity/childhood/basics.html
8. http://www.who.int/dietphysicalactivity/childhood/approaches/en/

13.3.3 Interventions

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Interventions
INTERVENTIONS IN WEIGHT MANAGEMENT IN CASES OF OBESITY AND OVERWEIGHT

Interventions in weight management in cases of obesity and overweight

Section 10.3.3.1 Energy and Body composition Weight management Interventions

Abstract

A small percentage of obesity cases may be caused by genetic and endocrine reasons, but the large majority of cases of obesity are caused by environment reasons (socio-economic environment, inappropriate diet and lack of physical activity). The intervention has to be individual and normally consist in changing lifestyle (better nutrition, increase physical activity and when required for obesity type II and III the prescription of medicine and/or surgery).

Keywords: emotions, obesity, overweight, intervention, Mediterranean diet, exercise

Interventions in weight management in cases of obesity and overweight

Introduction

A small percentage of obesity cases may be caused by genetic and endocrine reasons, but the large majority of cases of obesity are caused by environment reasons (inappropriate diet and lack of physical activity). Therefore the treatment of obesity has to be individual and customized for a given patient. In order to perform an appropriate intervention it is necessary to know the factors which have contributed to the obesity in a particular individual. It is easier and cheaper to prevent the pandemic obesity than to treat the pandemic obesity, once it has been established. The intervention has to be individual and normally consist in changing lifestyle (better nutrition, increase physical activity and when required for obesity type II and III the prescription of medicine and/or the bariatric surgery, bypass, etc.).

Influence of genetic endowment

The genetic factors predisposing to obesity are not yet well understood. A genome-wide search for type 2 diabetes-susceptibility genes identified a common variant in the FTO (fat mass and obesity associated) gene that predisposes to diabetes through an effect on body mass index (BMI). To identify common variants influencing body mass index (BMI), the study have analyzed genome-wide association data from 16,876 individuals of European descent. The main results have confirmed the BMI association in 60,352 adults (per-allele effect = 0.05 Z-score units; P = 2.8 x 10(-15)) and 5,988 children aged 7–11 (0.13 Z-score units; P = 1.5 x 10(-8)). In case-control analyses (n = 10,583), the odds for severe childhood obesity reached 1.30 (P = 8.0 x 10(-11)) (1)

Other studies have shown as well that In European general populations, the combined effects of common polymorphisms in FTO and MC4R are therefore additive, predictive of obesity and T2D, and may be influenced by interactions with physical activity levels and gender, respectively (2)

Common MC4R variants contribute to variation in BMI and obesity risk in the general population. Of particular interest is the finding from genome-wide association studies that suggests that the region downstream of MC4R contributes to its regulation (3)

According to the findings of a recent study, people who have a mutation in the gene APOA2 (which regulates a component of HDL or good cholesterol) have a higher risk of obesity if they have a diet rich in saturated fats. The CC genotype was associated with a 6.8% greater BMI in those consuming a high (P = 0.018), but not a low (P = 0.316) saturated fat diet (4)

Complex interaction of factors contributing to obesity

The inappropriate diet or the lack of physical activity may be due to multiple causes: · Bad emotional control (stress, depression, anxiety, compulsory behaviour, etc.) · Poor socio-economic environment (emotional support, frequency of friends, marital status changes, and a Social Relationship) · Lack of education · Bad food choices · Eating abroad frequently · And so on

Bad emotional control (stress, depression, anxiety, compulsory behaviour, etc.)

An important factor in the failure to achieve a correct weight management are bad handling of emotions. It is well known that our emotions have a powerful effect on our food choices and eating habits. Found empirical evidence that the influence of emotions on eating behavior is stronger in obese than in non-obese and dieters in relation to people who do not practice rigid diets (1) It has also been suggested that the emotion itself can not be responsible for excessive intake but rather, the real cause of overweight, how emotion is fronted by person (6,7) Only by knowing the emotional factors one can reinforce healthy habits that allow us to control weight. Therefore in emotional eaters to control overweight and obesity is recommended to follow cognitive therapy to control emotions better, a healthy diet and regular exercise practice. In a longitudinal study of 6 months with 41 sedentary obese people which have lost an average of 8% of their weight and 41 physically active non-obese people. The influence of emotions in their food intake was assesed by means of a questionnaire (Garaulet M., 2010) (8)

The most significant findings have been:

A lower BMI better emotional control intake. The higher the emotional score, less amount of weight lost. Women have been more influenced by their emotions than men. The weight control strategy was sedentary people use diets. Instead cyclists do by controlling the amount of exercise they do.

Psycological factors:

According to research conducted at the University Hospital Infanta Leonor de Madrid, obese people are not allways happy. According to results presented by the XVI congress of psquiatry 2012 in Bilbao, Spain (10) · 31% of obese patients had presented an anxiety disorder associated with obesity · 35% had a history of a depressive disorder. · 17% of obese people "have a history of having anorexia nervosa and bulimia nervosa · 10% revealed having had a disorder in impulse control · The report also shows a high prevalence of attention deficit disorder and hyperactivity disorder (ADHD) among patients analyzed: · 20.4% of patients had ADHD, a figure five times higher than expected in the general population · In addition, 62% of the patients reported regular dieting 15% had tried dieting organized more than 5 times throughout his life.

Choosing a healthy Diet to prevent and to reverse obesity

The inappropriate diet or the lack of control of the energy balance are the main contributors to obesity. For instance beverages, cakes and sugar consumption is contributing greatly to world obesity. The appropriate diet has to be healthy, complete in food groups, palatable and easy to flollow, otherways it will be abandonned sooner or later. The MD has demonstrated to be a good choice; as well as other diets followed by Japonneese, vegetarian people, and so on. The Mediterranean diet is rich in nutrients such as vitamins, minerals, antioxidants, fibre, omega-3 fatty acids (from fish) and monounsaturated fatty acids (from olive oil), whose beneficial effects on health have been widely demonstrated (11)

These studies show as well the progressive abandonment of the MD and the gradual progress of cardiovascular diseases and chronic diseases in the world ; particularly in countries like China, India, Mexico and Arab countries. The most critical point is the pandemia of childhood obesity (11,12)

A logitudinal study which included 6319 participans within thr SUN Project have demonstrated that adherence to Mediterranean diet was inversely associated with weight gain (13) Another logitudinal study which included 11 015 participants with 4 years of follow-up in the SUN Project have demonstrated a significant direct association between adherence to Mediterranean diet and all the physical and most mental health domains (vitality, social functioning and role emotional) (14) Adherence to the Mediterranean diet was associated with higher scoring for self-perceived health according to cross-sectional survey made in Catalonia Spain, among a random sample of the 35-74-year-old population (3910 men and 4285 women) in 2000 and 2005 (15.)

Choosing a meals distribution and timing

Another factor to be taken into account in therapeutic strategies should incorporate not macronutrient distribution in addition to the caloric intake. Five meals distributed along the day are recommended. The time clock is as well important and is influenced by the CLOCK gene polymorphism. Late lunch eaters lost less weight and displayed a slower weight-loss rate during the 20 weeks of treatment than early eaters (5 vs. 12% weight loss respectively). Late eaters were more evening types, had less energetic breakfasts and skipped breakfast more frequently that early eaters. CLOCK rs4580704 single nucleotide polymorphism (SNP) associated with the timing of the main meal with a higher frequency of minor allele (C) carriers among the late eaters (Garaulet M., P Gómez-Abellán, J J Alburquerque-Béjar, Y-C Lee, J M Ordovás and F A J L Scheer (2013) (16)

Choosing a program of physical activity to prevent and to reverse obesity

There are a great variety of physical activity programs which could be used in weight management, it is essential to perform aerobic exercise as well a strength and stretching exercises. The program has to have on a weekly basis at least 150 minutes of moderate aerobic activity (the ones preferred by one: walking, bicycling, swimming, etc), or at least 75 minutes of vigorous exercise, or the combination of both. Experts have found that participating in high intensity interval workouts are more successful at losing body fat. These intensity sessions put you at higher risk for injury and burnout. High intensity exercise is possible if you are fit, if it is not yet the case you need a training program that on a weekly basis increments the duration and intensity of tour physical activity. High intensity exercise also requires low intensity recovery time in the days following the session. This is where careful exercise programming comes into play.

It is important to engage in sport teams in our locality. This will prevent the abandon of the exercise program.

The benefits of physical exercise in the prevention of overweight and obesity are well documented. Regular physical activity reduces heart diseases , certain types of cancer and also helps maintain healthy body weight (17,18). The 2008 Physical Activity Guidelines for Americans (19) , suggests incorporating a minimum weekly total of two and a half hours of moderate-to-vigorous intensity physical activity, spread over at least five days of the week. Exercising five or more hours per week is recommended for weight loss. The calories burned during exercise depends on each individual anthropometrical parameters (gender, weight, physical conditions, fitness, etc.). We have to set our goals of intensity and duration of the exercise on a weekly basis and when a goal has been met, we have to choose a higher goal. It is interesting to focus on the fact that exercising and eating certain foods, like olive oil and foods rich in fiber, are useful to control the appetite. Therefore we have to use foods low dense on energy after exercising to facilitate weight management.

A recent study with nine female runners and ten walkers completed a 60 min moderate-intensity (70% VO2max) run or walk, or 60 min rest The runners often consumed fewer calories than they burned during the run (20). Other studies suggests as well that long- and short-acting signals interact to alter hypothalamic sensitivity to satiation signals (21) which could influence eating behaviour following exercise of moderate intensity.

Study case: Longitudinal study of six months of intervention in obese people

 Some of this information has been published in article Nutr Hosp. 2012;27(6):2148-2150

Introduction

The influence of emotions on the intake is stronger in sedentary, obese dieters.

Objective

To study the influence of emotions on the food intake of sedentary and physically active people. To study weight control strategies used by those persons.

Methods

We have performed a longitudinal observational study of weight loss with dietary intervention of 6 months in Madrid Pharmacies. 41 sedentary people and 41 physically active people have participated. The emotional score was obtained by questionnaire "emotional eater" (Garaulet M., 2010) (22). The score can be classified as: Dining little emotional (0-10 points); Moderately emotional (11-20points), very emotional. (21-30points).

Results

Anthropometrical data

Sedentary people Age = 53.9 ± 12.4 years, BMI = 33.6 ± 4.9 kg/m2. N=10 men and 31 women. Weight 87.5 ± 14.5 Kg. Weight loss was significant (10.2% kg in 6 months) The emotional eater score were as average= 13.2 ± 4.4 points over 30 points for sedentary people (13.1 points in men and 13.4 points in women). In cyclists emotional eater score were as average = 7.1 ± 3.7, they were significantly less emotional eaters than sedentary people (p <0.001). The most influential emotional factors were: Cravings and intake of excessive food in men. Binge eating and Obsession for food in women Little emotional eaters have lost more weight than very emotional eaters (12% vs 8%, respectively.). Correlation coefficient = -0.39. Active people Age = 49.9 ± 10.4 years, BMI = 23.1 ± 2.1 kg/m2. N=41 men. Weight 70.5 ± 10.5 Kg.

Intervention sedentary people

Average Hypo-caloric diet: Daily Expenditure = 2000 Kcal Daily Intake = 1700 Kcal Do not skip Breakfast Lunch before 15h Dinner at least two hours before going to bed Exercise = walking 30 to 60 min/day Weight evolution during 6 months intervention

START M0	MONTH 1	MONTH 2	MONTH 3	MONTH 4	MONTH 5	MONTH 6
weight loss (Kg)	2.7	2.3	1.7	0.98	1.39	1.5

Total WEIGHT LOSS = 10.2%

Intervention active cyclists

Average Iso-caloric diet: Daily Expenditure = 3000 Kcal Daily Intake = 2980 Kcal Exercise = cycling 90 to 120 min/day Weight evolution during 6 months intervention

START M0	MONTH 1	MONTH 2	MONTH 3	MONTH 4	MONTH 5	MONTH 6
weight loss (Kg)	0.7	0.8	0.9	0.7	0.9	0.5

Total WEIGHT LOSS = 0.7%

Conclusion

The intervention based on hypo-caloric diet and increasing physical exercise by sedentary people was effective. The higher was the emotional score, the lower was the amount of weight lost and higher value of the BMI The very emotional eaters have lost less weight than low emotional eaters. The weight management strategy of sedentary people was recurrent dieting. By the contrary the cyclists weight management strategy was controlling duration and intensity of physical exercise.

Medications

There are a number of medications that can be prescribed that help maintain weight. Although some of these are available over-the-counter, it is highly important that you contact your doctor before beginning a new regiment. All of the following medications should not be taken if pregnant or breast-feeding, as there can be serious effects on the child. You should inform your doctor if you have any heart conditions, or if you have had any alcohol or drug addictions in the past. Medication is only expected to work when used in conjunction with proper diet and exercise.

Orlistat: works by blocking the body’s absorption of fat. The medication can be either prescribed by a doctor (Xenical) or bought over-the-counter at a pharmacy (Alli). The pill is taken with each meal that contains fat. There are some complications that may occur. Taking Orlistat means your body may not be able to absorb fat-soluble vitamins, so a supplement may be suggested by a physician. The pill should be taken either during a meal, or up to one hour after a meal. 23 24

Belviq: generic Lorcaserin, works by curbing your appetite. Most often, it is used in patients who are considered obese, and usually also have high cholesterol, diabetes, or a higher than normal blood pressure. One dose, generally one pill at 10 mg, is taken twice a day, or as prescribed by a doctor. Complications have been seen in those who are also taking antidepression medications. 25

Contrave: generic Bupropion and Naltrexone, curb the appetite as well as lessen the impact of addiction on the body. The ideal patient for Contrave is someone who is considered obese. Burpropion is an antidepressant, which can cause a decrease in appetite. It is important to distinguish that while it can be given to cease nicotine addictions, it should not be used to treat of psychiatric conditions. Contrave has been known to cause problems when taken with high-fat meals, especially in those with epilepsy. 26

Phentermine: an appetite suppressant, usually taken before you eat breakfast. It has been known to cause sleep disruption, as it affects the central nervous system, so it should be taken no later than 6 pm. This is the only medication listed that is only taken for a short-term medication, not to be taken for 3+ months like the others. 27

As with taking any medications, it is important to take the proper dosage. Contact medical services if you suspect you have taken more than the prescribed amount, or call the American Association of Poison Control Centers: 1-(800)-222-1222

References

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Surgery