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Abstract Obesity and Weight Loss

Abstract Obesity and Weight Loss

Dietary therapy


Body weight regulation
Dietary measurements
Dietary therapy

Body weight regulation

A growing body of evidence suggests that energy balance (the difference between energy intake and expenditure) and body fuel stores in the form of adipose tissue are maintained by the body within a narrow range.

Regulation is mediated by the secretion of hormonal signals into the circulation in proportion to body adipose stores and their subsequent actions on brain systems that control caloric intake and energy expenditure.

Recent scientific break-throughs have identified the key components of this physiologic system. These include the circulating signals, leptin (the hormone encoded by the obesity gene that is secreted by fat cells) and the pancreatic hormone insulin; and brain peptides such as neuropeptide Y, which is released from nerve terminals in the hypothalamus to elicit changes in feeding behavior and energy expenditure that mediate adaptive changes in energy balance.

As our understanding of this weight-regulatory system increases, new insights into the causes of human obesity are likely to follow. Such insights may yield improvements in the medical and nutrition management of obese patients.

Schwartz MW & Seeley RJ: The new biology of body weight regulation. J Am Diet Assoc, 1997 Jan, 97:1, 54-8; quiz 59-60.

Dietary measurements

Substantial dietary underreporting questions the validity of dietary measurements of energy intake (EI).

Compared the value of a 7-day prospective dietary record (7dDR) with a computer program-based diet history (DH).

Underreporting [i.e. a difference between EI and EE (delta E = EI - EE)] of 20% or more was seen in 48% (7dDR, mean -1,047 kcal/day, range -616 to -1,895, or -38.8% of EE) or 48% (DH, -1,151 kcal/day, -594 to -2,057 kcal/day, or -42.3% of EE).

At the individual level dietary underreporting is influenced by the dietary assessment tool.

K”rtzinger I: Dietary underreporting: validity of dietary measurements of energy intake using a 7-day dietary record and a diet history in non-obese subjects. Ann Nutr Metab, 1997, 41:1, 37-44.

Dietary therapy

The effect of weight loss with anorectic medications on sleep apnea, non-insulin-dependent diabetes, and steatohepatitis is illustrated in three cases from practice in a clinical nutrition setting. Prevention of obesity, a chronic disorder, is preferable, but when obesity becomes a major obstacle in the care of patients with respiratory, cardiovascular, and metabolic disorders and osteoarthritis, an intense course of weight reduction using anorectic medications under medical and dietetic guidance is essential for patients' survival and reduction of medical cost.

DeMeo MT et al., Three cases of comprehensive dietary therapy and pharmacotherapy of patients with complex obesity-related diseases. Nutr Rev, 1997 Aug, 55:8, 297-302.


The introduction of low-fat, high-complex carbohydrate diets far the prevention and treatment of obesity was based on the causal link established between dietary fat and body fatness.

Observational and mechanistic studies show that because fat possesses a lower satiating power than carbohydrate and protein, a diet rich in fat can increase energy intake. The propensity to gain weight is enhanced in susceptible persons, particularly sedentary people who have a genetic predisposition to obesity.

Low-fat diets cause weight loss proportional to pretreatment body weight in a dose dependent manner; that is, weight loss is correlated positively to the reduction in dietary fat content.

A reduction of 10% fat energy produces an average 5-kg weight loss in obese persons. As with traditional caloric counting diets, obese persons lose weight only if they adhere to the prescribed low-fat diet. Failure to achieve a weight loss and to maintain it may be attributed in part to lack of adherence to the diet.

After a major weight loss, an ad libitum low-fat diet program appears to be superior to caloric counting in maintaining the weight loss 2 years later. Replacing some fat with protein instead of carbohydrate may increase the weight loss further.

Moreover, fat substitutes may make it easier to prevent and treat obesity by making the diet palatable.

Astrup A et al., The role of low-fat diets and fat substitutes in body weight management: what have we learned from clinical studies? J Am Diet Assoc, 1997 Jul, 97:7 Suppl, S82-7.

TV viewing


Inactivity and Television Viewing
Television viewing

Inactivity and Television Viewing

There is a documented increase in the prevalence of childhood obesity in the United States. The authors have identified television viewing as a strong risk factor for this.

Population and dietary intake surveys actually show a possible reduced intake of mean energy among children and adolescents during the period when obesity is increasing. This data suggests decreases in activity reduce lean body mass and lower energy requirements.

They conclude a multifactorial approach involving diet, exercise and restriction of television viewing and other sedentary activities be instituted to slow "the fattening of America".

Gortmaker, SL et al.,Inactivity, Diet and The Fattening of America. JADA, September 1990;90(9):1247-1252.

Television viewing

Measured energy expenditure (EE) of television viewing, sitting, and resting and duration of self-selected television viewing in obese and non-obese men and women.

Rates of EE for television viewing, adjusted for differences in body composition were 18% higher than resting metabolic rate (RMR), but similar to rates of other sedentary activities. There were no significant differences between obese and non-obese subjects in metabolic rates during resting, television viewing, and other sedentary activities.

Average time of self-selected television viewing was significantly greater in obese than in non-obese subjects and also in women than in men.

EE rate for television viewing in adults is higher than RMR and similar to other sedentary activities. Obese adults choose television viewing as a form of leisure activity more often than non-obese individuals and as a result they could significantly reduce other forms of physical activities and total daily EE.

Buchowski MS & Sun M: Energy expenditure, television viewing and obesity. Int J Obes Relat Metab Disord, 1996 Mar, 20:3, 236-44.

Lipids & Obesity


Obesity accentuates the known risk factors for atherosclerotic disease: dyslipidemia, hypertension, glucose intolerance and insulin resistance.

Among other risk factors, obesity is also characterized by a series of lipid disturbances (such as hypercholesterolemia), high fasting (and postprandial) triglyceride levels, low HDL cholesterol, high apolipoprotein B, high small dense lipoprotein particles and alterations of serum and tissue LPL-activity.

Extensive though this list is, it still does not fully explain atherogenesis. There remains a major role for oxidized LDL and VLDL particles.

Although obesity is characterized by dyslipidemia, less is known about the oxidation capacity of lipoproteins in obese subjects.

We measured the oxidizability in vitro in 21 premenopausal women and compared them to 18 age-matched controls. The oxidizability of the non-HDL fraction is evaluated by measuring the fluorescence and thiobarbituric acid reactive substances (TBARS: MDA nM/mg non-HDL) at different time intervals of incubation. TBARS formation increased linearly with the increase of lipids both in non-obese and obese subjects.

Van-Gaal-LF et al: Human obesity: from lipid abnormalities to lipid oxidation. Int-J-Obes-Relat-Metab-Disord. 1995 Sep; 19 Suppl 3: S21-6.

Prevalence of Obesity


Overweight and obese adults are at increased risk for morbidity and mortality associated with many acute and chronic medical conditions, including hypertension, dyslipidemia, coronary heart disease, diabetes mellitus, gallbladder disease, respiratory disease, some types of cancer, gout, and arthritis.

In addition, overweight during childhood and adolescence is associated with overweight during adulthood, and reports have documented an increase in the prevalence of overweight among children, adolescents, and adults from 1976-1980 to 1988-1991.

Data from CDC's Third National Health and Nutrition Examination Survey (NHANES III) (1988-1994) provided the most recent national estimates of overweight among children (ages 6-11 years), adolescents (aged 12-17 years), and adults (aged > or = 20 years) in the United States.

Findings indicate the prevalence of overweight in the United States has continued to increase.

Anonymous: Update: prevalence of overweight among children, adolescents, and adults--United States, 1988-1994. MMWR Morb Mortal Wkly Rep, 1997 Mar 7, 46:9, 198-202.

Stress & Obesity

An obesity specialist notes patients tend to lose weight from reduction in food intake and then gain the weight back by overeating. This usually results in a weight past their original weight. Six to seven weeks following the stressful event about 40% of these patients begin to eat excessively.

Stress can come from home or work. Normal weight men adapt to stress differently than obese men do.

Simonson, M: Obesity May be Linked to Poor Management of Stress. (Interview.) Obesity 90 Update, September/October 1990;3.

Binge eating & Obesity

Investigated the subjective and physiological cephalic phase reactivity to food in obese binge-eating women.

The cephalic phase response test consisted of baseline, anticipation, food exposure, and free eating periods. Serum insulin, free fatty acids, and plasma glucose concentrations as well as salivation, feeling of hunger, and desire to eat were repeatedly measured during the test.

During the food exposure, the binge eaters reported more desire to eat than nonbinge eaters. No differences were found between the groups in the physiological cephalic phase responses except for the lower salivation in the binge eaters during the food exposure. The amount of food eaten after the food exposure was similar in both groups.

Binge-eating women are characterized by stronger subjective but not stronger physiological cephalic phase reactivity to food.

Karhunen LJ et al., Subjective and physiological cephalic phase responses to food in obese binge-eating women. Int J Eat Disord, 1997 May, 21:4, 321-8.

Body Mass Index & Obesity


Body Mass Index

Body Mass Index

Absolute weight loss may not always be the best measure of adherence and response to therapy in obese adolescents if weight gain owing to linear growth is not considered.

Compared short-term absolute weight and height changes with changes in body mass index (BMI) in a group of severely obese adolescents to determine the most meaningful measure of treatment response.

Weight, height, and BMI at the initial visit and at the most recent visit were compared.

While 48% of our population actually lost weight, 78% either had no change or a decrease in BMI during the observation period. Differences between initial and most recent heights and BMIs were statistically significant, but weight changes were not significant.

In addition to weight, BMI should be routinely used and reported when monitoring the response to specific interventions in growing adolescents. Evaluation of weight alone may underestimate the adolescent's adherence to treatment goals.

Smith JC et al., Use of body mass index to monitor treatment of obese adolescents. J Adolesc Health, 1997 Jun, 20:6, 466-9.


Drugs & Obesity


Among drugs which cause weight gain, the tricyclic antidepressant medications are a drug class producing persistent and problematic body weight gain in many treated patients.

Major depressive illness is often associated with reductions in appetite and body weight, and treatment with antidepressants effectively restores mood, appetite and weight. However, a frequent complaint of patients treated with tricyclic drugs is of excessive and unwanted weight gain, often times resulting in medication noncompliance.

Reviewed the incidence of weight gain during acute and chronic treatment with different, frequently prescribed antidepressant drugs, as well as possible mechanisms by which such drugs alter caloric intake and expenditure, contributing to drug-induced weight gain.

Fernstrom MH: Drugs that cause weight gain. Obes Res, 1995 Nov, 3 Suppl 4:, 435S-439S.


Examined the rationale for long-term use of medications in the management of obesity, their safety and efficacy, and risks and benefits of treatment.

The long-term use of medications in the management of obesity is consistent with the current consensus that obesity responds poorly to short-term interventions. Net weight loss attributable to medication is modest, ranging from 2 to 10 kg, but patients taking active drug are more likely to lose 10% or more of initial body weight. Weight loss tends to reach a plateau by 6 months.

Pharmacotherapy for obesity, when combined with appropriate behavioral approaches to change diet and physical activity, helps some obese patients lose weight and maintain weight loss for at least 1 year.

There is little justification for the short-term use of anorexiant medications, but few studies have evaluated their safety and efficacy for more than 1 year. Until more data are available, pharmacotherapy cannot be recommended for routine use in obese individuals, although it may be helpful in carefully selected patients.

Anonymous: Long-term pharmacotherapy in the management of obesity. National Task Force on the Prevention and Treatment of Obesity. JAMA, 1996 Dec 18, 276:23, 1907-15.

Childhood Obesity


Childhood obesity
Children and adolescents
Obese children

Childhood obesity

Obesity is a common nutritional disturbance in children, ranging from 18% to 30% in children of various ages. It is even more problematic among ethnically diverse populations. Because childhood is a critical period for the initiation of obesity, appropriate measurement and assessment of children at risk are essential.

Keller C & Stevens KR: Childhood obesity: measurement and risk assessment. Pediatr Nurs, 1996 Nov-Dec, 22:6, 494-9.

Children and adolescents

A recent improvement in our ability to measure energy expenditure, body composition and fat distribution in children.

The key findings are:
· Total energy expenditure in young children is approximately 25% lower than current recommendations for energy intake and revised recommendations are necessary;
· Reduced energy expenditure, however, does not necessarily explain the greater prevalence of obesity in the population as a whole or in sub-groups at greater risk of obesity;
· Qualitative aspects of physical activity (e.g. Time, intensity) may be more important than the energy expenditure of physical activity in the regulation of body composition;
· For body composition assessment, dxa is emerging as a technique which can substantially improve the accuracy and standardization in children;
· Body fat begins to accumulate in the obese;
· Waist:hip ratio or waist circumference are inadequate markers of intra-abdominal adipose tissue in children and adolescents; finally,
· The early accumulation of fat in the intra-abdominal region is significantly related to the development of adverse health effects, including dyslipidaemia and glucose intolerance.

Goran MI: Energy expenditure, body composition, and disease risk in children and adolescents. Proc Nutr Soc, 1997 Mar, 56:1B, 195-209.

Obese children

Investigated the influence of nutrition and exercise interventions within cognitive/behavioral and public health formats on weight and blood lipid profiles in obese children.

Three conditions were compared over 16 sessions:

nutrition and eating-habit change followed by exercise (NE),
exercise followed by nutrition and eating-habit change (EN), and
an information control (INFO).

NE and EN were presented in a cognitive/ behavioral framework which focused on the development of self-regulation whereas the INFO condition received the same material in a public health/educational model.

NE and EN participants evidenced modest, yet significant, reductions in weight and blood lipids, and the impact of these two interventions endured at a five-year follow-up.

In contrast, INFO participants displayed stable weight and blood lipids during the course of the program, and most remained morbidly obese at follow-up.

Improved nutrition, increased physical activity and fitness were significantly correlated with weight and lipid reductions.

Johnson WG et al., Dietary and exercise interventions for juvenile obesity: long-term effect of behavioral and public health models. Obes Res, 1997 May, 5:3, 257-61.

Energy expenditure


Energy expenditure
Exercise (2)

Energy expenditure

Explored the best method of adjusting energy expended on physical activity (AEE) for differences in body size. Many publications have expressed AEE per kg body weight (i.e. using weight 1.0 as denominator). This makes the unjustified assumption that all activities are weight-dependent.

Analysis proved that weight 1.0 over-corrects for size differences and yields invalid conclusions about relationships between physical activity and obesity. An exponent close to 0.5 is more appropriate for sedentary lifestyles. However the correct exponent is itself dependent on the relative mix of weight-dependent and non-weight-dependent activities undertaken.

Great caution must be exercised when interpreting AEE data from individuals of markedly different body sizes.

Prentice AM et al., Physical activity and obesity: problems in correcting expenditure for body size. Int J Obes Relat Metab Disord, 1996 Jul, 20:7, 688-91.

Exercise (1)

In recent times, affluent societies have become less physically active, and this has undoubtedly contributed to the increased incidence of obesity. Formal programs of exercise training can reduce body weight and fat, but, in many cases, the changes produced by exercise are small.

When combined with energy restriction, exercise results in little further weight loss, but there is a strong trend for a greater loss of body fat. Thus, during diet-induced weight loss, added exercise seems to accelerate fat loss and maintain lean body mass, a condition which may prevent a decline in RMR. It is becoming increasingly clear that weight loss is better maintained when exercise is part of a weight-reducing program.

Furthermore, following a period of diet-induced weight loss, participation in regular exercise amounting to an energy expenditure of more than 1500 kcal/week will result in more successful maintenance of the lesser weight. An emphasis should be placed on adopting life-long habits conducive to weight control and overall health rather than temporary measures for weight loss.

Regular physical activity has the potential to reverse insulin resistance, improve cardiovascular function and the blood lipid profile, and control high blood pressure. Overweight individuals can obtain these important benefits even if body weight is not completely normalized during a program of regular physical activity. This should help alleviate problems of diabetes, heart disease, and hypertension often associated with being overweight.

The best recommendation comes from the American College of Sports Medicine. Persons are urged to engage in regular physical activity which promotes a daily energy expenditure of at least 300 kcal/day and to choose from a variety of activities, in particular, those which are enjoyable and that can be continued for life.

Zachwieja JJ: Exercise as treatment for obesity. Endocrinol Metab Clin North Am, 1996 Dec, 25:4, 965-88.

Exercise (2)

Exercise is frequently identified as a predictor of weight maintenance after elective weight loss in retrospective studies of treatments for obesity.

Tested whether physical activity, measured soon after weight loss, predicted weight maintenance and determined how much physical activity was required to optimize maintenance.

Analyses of weight regain as a function of energy expended in physical activity indicated a threshold for weight maintenance of 47 kJ x kg body wt(-1) x d(-1). This corresponds to an average of 80 min/d of moderate activity or 35 min/d of vigorous activity added to a sedentary lifestyle.

Schoeller DA et al., How much physical activity is needed to minimize weight gain in previously obese women? Am J Clin Nutr, 1997 Sep, 66:3, 551-6.

Fetal origins of Obesity

Fetal origins (1)

Close relationships exist between patterns of intra-uterine growth and the risk of ischaemic heart disease, hypertension, diabetes, insulin-resistance syndrome, obesity and some cancers later in life.

Earlier studies placed emphasis on low birth weight and reduced growth, but it is now clear that disproportions in early growth are of great importance. Disproportion may be identified as disproportions of fetal and placental growth (and the risk of high blood pressure), or in head circumference, length and weight.

Hypothetically, the availability of nutrients at different times during gestation, by interacting with the maternal and fetal hormonal profile, predisposes to different patterns of growth. The same interaction programmes critical metabolic functions and determines the metabolic capacity at all later ages.

People who were exposed to severe undernutrition during the Dutch hunger winter showed increased adiposity if the exposure was during early pregnancy, but decreased adiposity if the exposure was during late pregnancy.

In men born in the UK, those with evidence of retarded fetal growth had significantly greater waist/hip circumference ratios for any given body mass index (the ratio fell with increasing weight at one year of age).

In Mexican-Americans and non-Hispanic Caucasian Americans, people in the lowest third of birth weight had more truncal fat than those in the highest third.

Offspring of rats exposed to marginally reduced protein intakes during pregnancy manifest a similar pattern of growth and metabolic change to that seen in humans, with perturbations of appetite and body fat patterning.

Programming of the hypothalamus, especially the hypothalamic-pituitary-adrenal axis might be the mechanism through which these changes are brought about.

Jackson AA et al., Nutritional influences in early life upon obesity and body proportions.
Ciba Found Symp, 1996, 201:, 118-29; discussion 129-37, 188-93.

Genes & Obesity


Individual susceptibility to obesity is recognized to be influenced significantly by genetic inheritance. Recently, candidate obesity genes have been identified that may contribute to the inheritance of body fat mass and the partitioning of fat between central and peripheral fat depots.

In humans, sequence variation in at least 6 genes has been linked to increased body fatness and/or susceptibility to obesity. In addition, 5 other encoding genes have been linked to a disproportionate storage of fat in the abdominal region.

Roberts SB & Greenberg AS: The new obesity genes. Nutr Rev, 1996 Feb, 54:2 Pt 1, 41-9.

Genetic update

The social construction of overweight has meant that dieting is an experience of being a woman in Western society. Health promotion fails to counteract the cult of slimness and reinforces medicalized notions of the "problem" of overweight, legitimizing unnecessary dieting practices.

The issue of gender and dieting is used here to illustrate the need for interdisciplinary and qualitative approaches to the study of food and nutrition practices, before intervening to change those practices.

Lessick M & Keithley J: Obesity: genetic update and clinical implications. Appetite, 1996 Oct, 27:2, 97-108.

Immune response & Obesity

Immune response

Studied the effect of moderate energy restriction (4.19-5.44 MJ or 1200-1300 kcal per day) in obese females on a variety of both innate and adaptive immune function measures including mitogen-stimulated lymphocyte proliferative response, and monocyte and granulocyte phagocytosis and oxidative burst.

Data indicate that despite large differences in body fat mass between the obese and nonobese groups, immune function, as measured in this study, was similar between groups. Weight loss, however, even though relatively moderate (9.9 +/- 1.4 kg), was associated with significant decreases relative to the nonobese in several measures of T, B, monocyte and granulocyte function.

Data do not support the contention that mild-to-moderate obesity is associated with alterations in immune function. However, weight loss, even at a moderate rate, is associated with a decrease in the function of certain aspects of the immune system.

Nieman DC et al., Immune response to obesity and moderate weight loss. Int J Obes Relat Metab Disord, 1996 Apr, 20:4, 353-60.

Trends for Obesity

Trends in the prevalence of overweight between 1987 and 1993.

Between 1987 and 1993, the age-adjusted prevalence of overweight increased by 0.9% per year for both sexes (from 21.9% to 26.7% among men and from 20.6% to 25.4% among women).

This trend was observed in all subgroups of the population but was most notable for Black men (1.5% per year) and men living in the Northeast (1.4% per year).

The prevalence of overweight among American adults increased by 5% between 1987 and 1993. Efforts are needed to explore the causes of this adverse trend and to find effective strategies to prevent obesity.

Galuska DA et al., Trends in overweight among US adults from 1987 to 1993: a multistate telephone survey. Am J Public Health, 1996 Dec, 86:12, 1729-35.

School programs


Physical activity (elementary school children)
School health programs

Physical activity (elementary school children)

Obesity and low levels of physical and metabolic fitness are risk factors for cardiovascular disease and diabetes.

Schools have the opportunity, mechanisms, and personnel in place to deliver nutrition education, fitness activities, and a school food service that is nutritious and healthy.

Donnelly JE et al., Nutrition and physical activity program to attenuate obesity and promote physical and metabolic fitness in elementary school children. Obes Res, 1996 May, 4:3, 229-43.

School health programs

Healthy eating patterns in childhood and adolescence promote optimal childhood health, growth, and intellectual development; prevent immediate health problems, such as iron deficiency anemia, obesity, eating disorders, and dental caries; and may prevent long-term health problems, such as coronary heart disease, cancer, and stroke.

School health programs can help children and adolescents attain full educational potential and good health by providing them with the skills, social support, and environmental reinforcement they need to adopt long-term, healthy eating behaviors.

CDC guidelines include recommendations on 7 aspects of a school-based program to promote healthy eating: school policy on nutrition, a sequential, coordinated curriculum, appropriate instruction for students, integration of school food service and nutrition education, staff training; family and community involvement, and program evaluation.

Anonymous: Guidelines for school health programs to promote lifelong healthy eating. Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep, 1996 Jun 14, 45:RR-9, 1-41.

Insulin resistance & Obesity

Resistance to insulin

Insulin-mediated glucose uptake was independently associated with degree of obesity (inversely) and estimates of level of physical activity (directly). An independent relation between increased intake of vitamin A and insulin action was shown, i.e., the greater the intake of vitamin A, the more effective was insulin in stimulating glucose disposal.

However, there was no independent relation noted between insulin-mediated glucose disposal and estimates of the intake of carbohydrate, protein, amount or kind of fat, fiber, or vitamins C and E.

Individuals with estimates of vitamin A consumption > 10 000 IU/d had significantly lower plasma glucose and insulin responses to oral glucose, and insulin-mediated glucose disposal values that were higher than those whose estimated vitamin A intake was < 8000 IU/d.

Results suggest that vitamin A intake, but not intakes of vitamin C and E, fiber, fat, or carbohydrate is associated with enhanced insulin-mediated glucose disposal.

Facchini F: Relation between dietary vitamin intake and resistance to insulin-mediated glucose disposal in healthy volunteers. Am J Clin Nutr, 1996 Jun, 63:6, 946-9.

Morbidity & Obesity

Experts agree that overweight and obesity pose a significant public health problem in the United States.

Obesity is considered to be a complex, multifactorial disease involving genetics, physiology, psychology, and environment, and is influenced by cultural messages.

Comorbidities linked to obesity include coronary heart disease, stroke, hypertension, diabetes mellitus, gout, dyslipidemias, cholecystitis, and gallstones.

Wood OB & Popovich NG: Nonpharmacologic treatment of obesity. J Am Pharm Assoc (Wash), 1996 Nov, NS36:11, 636-50.

Macronutrient selection

Examinined the role of macronutrient selection in determining patterns of food intake in obese and non-obese women. [Food intake diaries.]

An ample choice of food items consisting of mainly one macronutrient each were offered 4 and 6 times per day, with different macronutrient compositions per day.

Selection, namely food choice that differs from random consumption, took place at breakfast in favour of carbohydrate, and at dinner in favour of fat.

Habituation, namely a decreased response on the same stimulus, occurred after the fourth exposure to a single macronutrient buffet. For protein this was expressed as a significantly increased satiety score per kJ ingested; for fat as a significant drop in hedonic value; for carbohydrate as a significantly increased desire for a different taste, all.

Compensation, i.e. a correction afterwards for an earlier unusual macronutrient composition, resulting in a close to usual macronutrient composition of 24 h food intake, occurred at dinner, for a previous unusually low fat and high carbohydrate intake.

A pattern of macronutrient intake was achieved by selection and compensation. Habituation occurred at the fourth exposure of a single macronutrient.

Westerterp-Plantenga MS et al., The role of macronutrient selection in determining patterns of food intake in obese and non-obese women. Eur J Clin Nutr, 1996 Sep, 50:9, 580-91.

Oxidation & Obesity

Oxidative hierarchy

When energy is in excess, the human body processes nutrients according to an oxidative hierarchy.

Excessive carbohydrate and protein intakes are disposed of by increased oxidation.

In contrast, excess fat intake does not promote its own oxidation in the short- and mid-term. This leads, in the long-term, to an increase in fat stores.

Although increased adiposity represents the common response to increased fat intake, there are interindividual differences in lipid oxidation (probably genetically determined) that may protect from or predispose to obesity.

Ravussin E & Tataranni PA: Dietary fat and human obesity. J Am Diet Assoc, 1997 Jul, 97:7 Suppl, S42-6.

Prevention of Obesity

Obesity is a serious, chronic medical condition which is associated with a wide range of debilitating and life-threatening conditions. It imposes huge financial burdens on health care systems and the community at large. Obesity develops over time and once it has done so, is difficult to treat.

Therefore, the prevention of weight gain offers the only truly effective means of controlling obesity.

The prevention and management of obesity in children should be considered a priority as there is a high risk of persistence into adulthood.

Gill TP: Key issues in the prevention of obesity. Br Med Bull, 1997, 53:2, 359-88.

Waist circumference & Obesity

Waist circumference (1)

Examined the relationship between waist circumference and cardiovascular risk factors during weight loss, and to consider possible waist reduction targets for weight management.

Waist reduction of 5-10 cm in Caucasian women, across a range of baseline BMI 25-50 kg/m2 or waist circumference 72-133 cm, may be used as guideline to encourage overweight women to achieve a realistic target with a high probability of health benefits.

Han TS et al., Waist circumference reduction and cardiovascular benefits during weight loss in women. Int J Obes Relat Metab Disord, 1997 Feb, 21:2, 127-34.

Waist circumference (2)

Assessed the influences of height and age on the differences in waist circumference between individuals of different stature.

Height and age had limited influences on the differences in waist between Caucasian subjects of different stature. Waist alone may be used to indicate adiposity or to reflect metabolic risk factors. In contrast, the influence of height on body weight is important.

Han TS et al., The influences of height and age on waist circumference as an index of adiposity in adults. Int J Obes Relat Metab Disord, 1997 Jan, 21:1, 83-9.

Wounds & Obesity

Morbid obesity is a chronic disease that manifests as a steady, slow, progressive increase in body weight. Because of both emotional and physical reasons, obese people resist pursuing healthcare and may be more difficult to care for.

Skin/wound problems which are common, yet more difficult to manage for these patients, include pressure ulcers, tracheostomy care (potentially resulting from ventilatory insufficiency), candidiasis, tape-related skin tears, incontinence and lymphedema.

Gallagher SM: Morbid obesity: a chronic disease with an impact on wounds and related problems. Ostomy Wound Manage, 1997 Jun, 43:5, 18-24, 26-7.


Weight loss & Obesity

The prevalence of obesity increased nearly 8% over the last decade. In response to the obesity epidemic in the United States. The National Institutes of Health Technology Assessment Conference Panel published "Methods for voluntary weight loss and control" in 1993.

Unfortunately, in 1996, the evidence suggests that the prevalence of obesity is still steadily increasing. Current trends predict that most Americans will struggle with weight problems and obesity in the future.

There have been no major advances in the treatment of obesity. Interventions produce short-term losses followed by weight regain, and no current treatments appear capable of producing permanent weight loss. Newer treatment approaches assume that obesity is a chronic disorder that requires a continuous care model of treatment.

Environmental changes and biological interventions aimed at correcting genetic and metabolic irregularities will be central to any efforts to stem the tide of obesity.

Goodrick GK et al., Methods for voluntary weight loss and control: update 1996. Nutrition, 1996 Oct, 12:10, 672-6.

Low Back Pain & Obesity

Examined the associations of low back pain symptoms with waist circumference, height, waist to hip ratio and body mass index, and tested the interactions between (1) waist circumference and height, and (2) waist to hip ratio and body mass index.

The prevalences of low back pain in men and women in the past 12 months were 46% and 52%, of whom 17% and 21% had low back pain for a total of 12 or more weeks, and 13% and 18% had symptoms suggestive of intervertebral disc herniation.

Women who are overweight, or with a large waist, have a significantly increased likelihood of low back pain. There are no significant interactions between waist and height, or waist to hip ratio and body mass index on low back pain symptoms.

Han TS: The prevalence of low back pain and associations with body fatness, fat distribution and height. Int J Obes Relat Metab Disord, 1997 Jul, 21:7, 600-7.

Nutrition factors & Obesity

Nutrition planning

The most sensible eating plans involve a wide selection of foods with a modest percentage of kilocalories as fat. The dietary pyramid developed by the US Government is an excellent basis for the construction of an eating plan for life.

The unfortunate fact is that individuals with the disease of obesity must behave differently than those who do not. This usually means that obese persons must eat differently than lean persons, and they must do this for their entire lives. Food is a critical part of the social fabric of our society.

Obese patients must select the series of compromises in eating plans and activity levels that can be maintained for life while still allowing a reasonable quality of life.

Atkinson RL: Role of nutrition planning in the treatment for obesity. Endocrinol Metab Clin North Am, 1996 Dec, 25:4, 955-64.

Counseling & Obesity


Nutritional counseling (Germany)
Nutrition guidance - primary care physicians (Holland)

Nutritional counseling (Germany)

There is consensus among all German health professionals, including primary care physicians, that a holistic approach to healthy living begins with good nutrition

75% attributed great importance to prevention in general and 92% to nutrition in particular, 65% were providing special programs such as "How to treat diabetes by myself" or "Reducing hypertension by losing weight."

The Heidelberg agreements are as follows:
1. Good nutritional counseling can reduce morbidity of important diseases,
2. Nutritional counseling must be improved in general practice,
3. Diagnosis-related written cases for systematic counseling should be available,
4. Family doctors should cooperate with nutritionists, and
5. For quality assurance, the three-level strategy of primary care should be recommended because of the positive results of the Bruchsal-Oestringen program (reduction of obesity and hypercholesterolemia).

The outcome of practice-based studies may encourage primary care physicians to spend more time and training on nutrition guidance.

Wiesemann A: Nutritional counseling in German general practices: a holistic approach. Am J Clin Nutr, 1997 Jun, 65:6 Suppl, 1957S-1962S.

Nutrition guidance - primary care physicians (Holland)

Studied the nutrition information seeking behavior of primary care physicians (PCPs) and also their implementation of different strategies of nutrition guidance of patients.

The two most important nutrition information sources for PCPs were a dietitian (72% of respondents) and the literature (34% of respondents). Eighty-five percent of PCPs reported that they were actively involved in seeking nutrition information.

For nutrition education of patients, PCPs gave personal information to patients, referred patients to a dietitian, and made publications available in the surgery.

As preferred methods of obtaining nutrition information themselves, PCPs listed scientific journals, postgraduate nutrition education, congresses and study days, and publications.

There are growing opportunities, challenges, and tools for PCPs to become more actively involved in nutrition guidance of patients.

Hiddink GJ: Information sources and strategies of nutrition guidance used by primary care physicians. Am J Clin Nutr, 1997 Jun, 65:6 Suppl, 1996S-2003S.


Low Birth weight

Low birth weight has been associated with several chronic diseases in adults, including hypertension, diabetes mellitus, and obesity.

Low birth weight was associated with an increased risk of hypertension and diabetes; high birth weight was associated with an increased risk of obesity.

Compared with men in the referent birth weight category (7.0 to 8.4 lb), men who weighed < 5.5 lb had an age-adjusted odds ratio for hypertension of 1.26 and for diabetes mellitus of 1.75.

Compared with men in the referent group, the age-adjusted odds ratio of being in the highest versus the lowest quintile of adult body mass index for men with birth weight > or = 10.0 lb was 2.08.

Curhan GC et al., Birth weight and adult hypertension, diabetes mellitus, and obesity in US men. Circulation, 1996 Dec 15, 94:12, 3246-50.

Low Birth weight (women)

Low birth weight has been associated with an increased risk of hypertension, and high birth weight has been associated with increased adult body mass index. Published studies on adults have included only a small number of women.

Compared with women in the middle category of birth weight (NHS I, 7.1 to 8.5 lb; NHS II, 7.0 to 8.4 lb), the age-adjusted odds ratio of hypertension in NHS I women with birth weights < 5.0 lb was 1.39; in NHS II, for birth weights < 5.5 lb, the age-adjusted odds ratio was 1.43.

In addition, compared with women in NHS I who weighed 7.1 to 8.5 lb at birth, those who weighed > 10 lb had an age-adjusted odds ratio of 1.62 of being in the highest versus the lowest (< 21.9 kg/ m2) quintile of body mass index in midlife. Similar results were seen in the NHS II cohort.

Early life exposures affecting birth weight may be important in the development of hypertension and obesity in adults.

Curhan GC et al., Birth weight and adult hypertension and obesity in women. Circulation, 1996 Sep 15, 94:6, 1310-5.

Caffeine, Ephedrine, Yohimbine

Caffeine, Ephedrine, Yohimbine

This study evaluated 9 obese women on a standard hypocaloric diet as a control group; 9 obese women receiving a standard hypocaloric diet in addition to epinephrine and caffeine twice a day; and 9 obese women receiving a hypocaloric diet, as well as caffeine, epinephrine, and yohimbine 2 times a day. Caffeine and ephedrine had no hemodynamic effect in resting patients. However, using these three drugs during cycloergometer exercise leads to an increase in cardiac work. Yohimbine should be excluded or utilized with caution in obese individuals with cardiovascular complications.

Waluga, Marek, et al: Cardiovascular Effects of Ephedrine, Caffeine and Yohimbine Measured by Thoracic Electrical Bioimpedance in Obese Women, Clinical Physiology, 1998;18(1):69- 76.



The underlying cause of some forms of obesity may be neuroendocrinological and therefore be based on genetics, according to this review. This study focuses on the results of the European Sibutramine Trial of Obesity Reduction and Maintenance, in which some patients did not sustain weight loss after intensive therapy. The author suggests that there is some organic component of the disease in those patients who do not respond to intensive treatment, and that extensive medical evaluations of non-responsive patients may help researchers better understand the etiology of obesity.
Lustig RH: The neuroendocrinology of obesity, Endocrinol Metab Clin North Am 2001 Sep;30(3):765-8

Glucose transport enhancers

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