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ISBN 1-84544-825-1
ISSN 0034-6659
Volume 35 Number 5 2005
Nutrition & Food Science Obesity
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Nutrition & Food Science
ISSN 0034-6659 Volume 35 Number 5 2005
Obesity Editor Dr Mabel Blades
Access this journal online _________________________
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Editorial board ___________________________________
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Editorial _________________________________________
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Healthy lifestyle project for overweight and obese children: a pilot study Mary Tyers ___________________________________________________
298
Effects of an over-the-counter herbal weight management product (Zotrim1 ) on weight and waist circumference in a sample of overweight women: a consumer study C.H.S. Ruxton, F. Hinton and C.E.L. Evans _________________________
303
Predictors of physician overweight and obesity in the USA: an empiric analysis John La Puma, Philippe Szapary and Kevin C. Maki __________________
315
Modern diets converging: the move to low GI/GR diets Shane Landon_________________________________________________
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CONTENTS
CONTENTS continued
Low levels of cholesterol/saturated fat index (CSI) in a Japanese-Brazilian diet Elizabeth Aparecida Ferraz da Silva Torres, Geni Rodrigues Sampaio, Cla´udia Moreira Nery Castellucci, Edeli Simioni de Abreu and Marly Augusto Cardoso _________________________________________
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Diet, lifestyle factors and symptoms of premenstrual syndrome Katie L. Oliver and G. Jill Davies __________________________________
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Nutritional profiling vs guideline daily amounts as a means of helping consumers make appropriate food choices Gaynor Bussell ________________________________________________
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Functional foods and nutraceuticals in the management of obesity Gursevak S. Kasbia_____________________________________________
344
The potential role of peanuts in the prevention of obesity Jennette Higgs _________________________________________________
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Waist to height ratio and the Ashwell1 shape chart could predict the health risks of obesity in adults and children in all ethnic groups Margaret Ashwell ______________________________________________
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Food facts ________________________________________
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Conference reports _______________________________
372
Book reviews _____________________________________
377
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EDITORIAL BOARD
John J.B. Anderson, PhD Professor of Nutrition, University of Carolina School of Public Health and School of Medicine, USA
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David C. Nieman, DrPH MPH FACSM Professor, Appalachian State University, USA
Professor Winston Craig Andrews University, Berrien Springs, MI, USA
Claire Seaman, BSc, MPhil, SRD Lecturer on Food Studies, Queen Margaret College, Edinburgh, UK Christopher Strugnell, BSc, PhD, MIFST University of Ulster at Jordanstown, Northern Ireland
Marcel Hebbelinck, PhD Professor, Laboratory Human Biometry, Vrije Universiteit Brussels, Belgium
Margaret Thorogood, PhD Senior Lecturer, London School of Hygiene and Tropical Medicine, UK
Ann Reed Mangels, PhD RD FADA Nutrition Advisor, Vegetarian Resource Group, USA
Dr Wendy Wrieden Centre for Public Health Nutrition Research, Ninewells Medical School, Dundee, UK
Dr Margaret Ashwell OBE Ashwell Associates (Independent Scientific Co-ordinators & Consultants) Ashwell, UK
Editorial
Editorial
Obesity is such a tremendous problem that it is with great enthusiasm that I have compiled this special issue of Nutrition & Food Science as I hope that it will be of help to anyone with an interest in the topic. This is the first special issue of Nutrition & Food Science that I have written and I have tried to include a number of papers from various authors on this important topic as well as general information of where to get further information from web sites, organisations and books. This issue of Nutrition & Food Science focuses on obesity from a number of perspectives. Obesity is considered by the World Health Organisation to constitute a world-wide epidemic. In the UK one in five adults is obese with one in four predicted to be obese by the year 2010. Not only is obesity linked with disorders such as Type 2 diabetes, hypertension, coronary heart disease, certain cancers and varicose veins but it also exacerbates problems such as joint and breathing disorders. People who are obese find that obesity adversely affects their lives with problems of purchasing clothes, bullying, fitting into bus, theatre and cinema seats, mobility problems, employment discrimination and difficulties with relationships to mention but a few. The life expectancy of anyone who is obese is reduced by nine years while it is reduced by seven years in those who smoke. Indeed in a survey of people’s biggest fears, surprisingly, becoming obese was considered to be a far greater fear than nuclear war! There are all types of strategies and theories as regards obesity. However, as a practising dietitian with a number of grossly obese patients it seems to me that there is no one approach that suits every person who is obese. Also the approach that is required may change with time.
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Mabel Blades
Nutrition & Food Science Vol. 35 No. 5, 2005 pp. 297 # Emerald Group Publishing Limited 0034-6659
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The current issue and full text archive of this journal is available at www.emeraldinsight.com/0034-6659.htm
Healthy lifestyle project for overweight and obese children: a pilot study Mary Tyers
298
Nutrition and Dietetic Department, University Hospital of North Staffordshire, Stoke-on-Trent, UK Abstract Purpose – To describe a year-long pilot programme, based at a leisure centre combining access to a modified version of the existing ‘‘Physical Activity Referral Scheme’’ (‘‘Exercise on Prescription’’) in North Staffordshire with dietary intervention. Design/methodology/approach – A small group of overweight and obese children and their families participated in a year-long programme with psychologist input in initial design. The programme entailed dietary intervention, incorporating behavioural approaches coupled with advice and encouragement to access physical activity opportunities. School nurses recruited 16 primary school-aged children whose BMI fell within the inclusion areas of the BMI centile charts for overweight or obesity. Findings – Sixteen children with their families were initially involved in the programme of dietary and physical activity intervention and encouragement. Twelve children completed the year. Ten of the 12 children (83 per cent) had an improved BMI centile status (three children marginally so). A total 75 per cent of children had an improved waist circumference centile by the end of the project. Dietary markers showed an all-round improvement in the quality of children’s diets. Children became more physically active, participants citing that they were walking more and most were achieving 16-30 more minutes a day in various forms of physical activity. Research limitations/implications – Statistical advice is sought to obtain numbers of children required to run a comparative study with a control group (dietary intervention only) alongside intervention described in pilot study. Originality/value – The number of children involved has been small but the scheme appears to have been an effective means of enabling children and their families to achieve a healthier weight and lifestyle over the period of the programme. Keywords Children (age groups), Obesity, Diet, Activity sampling, Schools, Nurses Paper type Research paper
Introduction Families with overweight and obese children are requesting help and would benefit from treatment programmes. There is a lack of evidence of the efficacy of treatment programmes for overweight and obese children. It appears (Health Development Agency, 2003) that targeting parents and children together (family based interventions involving at least one parent with physical activity and health promotion) is effective. It has been suggested (SIGN, 1996; NHS CRD 2002) that it would be beneficial to target Nutrition & Food Science Vol. 35 No. 5, 2005 pp. 298-302 # Emerald Group Publishing Limited 0034-6659 DOI 10.1108/00346650510625485
The North Staffordshire Directorate of Health Promotion who funded the Physical Activity Consultant and coordinate the Physical Activity Referral Scheme. School Nurses: Mary Cooke, Sue Needham and Sandy Hammond. Child and Adolescent Psychologist, Carol Martin. Glendale Leisure and Staffordshire Moorlands District Council. The Nutrition and Dietetic Department. University Hospital of North Staffordshire.
high risk children for more intensive treatment programmes based on a joint approach which can be summarised as involving: .
healthy eating,
.
increased physical activity,
.
behavioural approaches,
.
involvement and support of family.
The programme aimed to facilitate families making specific dietary changes, being involved in increased everyday activities and the children themselves in preferred activities at the local leisure centre. This would enable overweight or obese children achieve an improved BMI profile. Subjects School nurses recruited 16 primary school aged children (10 girls and 6 boys) initially to participate in the programme. Eight of the children were in receipt of free school meals indicating limited family income. Twelve children (7 girls and 5 boys) completed the year. Two children from one family discontinued the programme after an initial consultation and two more half way through the programme giving no reason, despite a letter requesting feedback being sent. Methodology The involvement of a Child and Adolescent Psychologist helped ensure that the programme was approached in a sensitive and non-stigmatising way. Children were included in the programme if BMI fell within the inclusion areas of the BMI centile charts for overweight or obesity. The International Obesity Task Force have recommended cut-offs on the British Childhood BMI charts for obesity and overweight in children. These correspond to the adult definitions of overweight (BMI >25) and obesity (BMI >30) at age 18 (Cole, 2000). There is some evidence however that BMI measurements alone which give no indication of body fat distribution, in children, may be masking even higher levels of overweight and obesity than is currently realised (McCarthy, 2003). Trends in waist circumference during the past 10-20 years have greatly exceeded those of body mass index particularly in girls. Measuring BMI alone is therefore likely to be underestimating the prevalence of obesity in young people. For this reason waist circumference data was collected at the beginning and end of project period. This information was related to the published waist circumference percentiles in British children aged 5-16.9 years (McCarthy, 2001). Dietary markers (intake of fruit and vegetables, sugary drinks, crisps and sweets and chocolates) giving an indication of the quality of diet taken were collected from detailed diet histories the beginning and end of the programme. Participants, always with at least one main carer, (other family members were encouraged to attend if possible) were given the opportunity of seeing the dietitian, during daytime, in at the leisure centre on 5 occasions over a yearlong period for dietary education and intervention. Dietary targets were agreed initially and at each subsequent appointment if needed. Motivational charts with stickers were used as suggested by the psychologist to encourage children make agreed changes. There were also dietary educational activities throughout the year. These included children collecting wrappers and pictures of foods and drinks consumed and placing them, after
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discussion, on a large Balance of Good Health mat. Children with their parents also completed a food diary forming another discussion point. Work sheets from the British Dietetic Associations Food First’s Eat 2 B Fit educational pack were also used to reinforce changes being negotiated with the families. The families also had the opportunity of receiving expert advice on achieving a more physically active lifestyle by a Physical Activity Consultant. This input was accessed by modifying an existing arrangement of the adult’s scheme whereby suitable patients are able to obtain a prescription from their G.P to access a 10 week course at the local leisure centre gym coupled with two consultations with a physical activity consultant. As most gym-based activities are unsuitable for children, the programme offered was modified to include, at no cost for the involved child, swimming, badminton, football, table tennis and trampolining. An important emphasis taken by the physical activity consultant, however, was that increasing everyday activities such as walking were of equal importance. British Heart Foundation resources were used to help reinforce and motivate children. At all times the whole family was encouraged to be involved in both aspects of the programme and make family based changes. With this in mind two family walks were organised specifically for the group of children and their families. Results Sixteen children with their families were initially involved in the programme of dietary and physical activity intervention and encouragement. Incidence of presence of family history of obesity and associated health problems as reported by the families (Table I). Ten of the12 children (83 per cent) had an improved BMI centile status (although three children only marginally so), one child stayed on the same centile and one child’s weight profile worsened. At the beginning of the programme 67 per cent children were obese and 33 per cent were overweight. At the end 56 per cent were obese and 44 per cent overweight. In total, 75 per cent of children had an improved waist circumference centile by the end of the project. Advice sought from a statistician deemed this was a pilot study with a small number of children. Results are represented graphically in Figure 1. Using dietary markers as an indication of altered diet it appeared that the children generally achieved a healthier diet by the end of the project (Table II). All participants claimed that they and their families have become more physically more active as a result of the scheme and plan to continue to be so. All participants cited that they were walking more and most were achieving 16-30 minutes of increased physical activity a day. Five children had guardians who themselves became participants on the Physical Activity Referral Scheme as a result of their children’s involvement. This probably indicates that whole families were becoming more physically active as a result of their children’s involvement in the programme. One child had not taken part in school P.E. for several years but was now doing so.
Table I.
Obesity Diabetes Heart Disease
One side of family
Both sides of family
44% (7) 25% (4) 25% (4)
50% (8) 25% (4) 44% (7)
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Figure 1.
Dietary marker Fruit and vegetable intake Frequency of sweets/ chocolate intake Frequency of crisp intake Sugary Drink Consumption
Pre-programme
Post-programme
Average intake 2 portions/ day. Average frequency of consumption 3/week Average intake of 5 packets/week 50% 50%
Average intake of 3.5 portions/day Average frequency of consumption 2/week Average intake reduced to 3 packets/ 92% 8%
Table II.
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Conclusion The number of children involved in this pilot programme has been small but the scheme appears to have been an effective means of enabling children and their families achieve a healthier lifestyle. This conclusion is based on patient and their families self reporting of attained physical activity levels and changes in dietary intake as indicated by dietary markers. However BMI profiles and waist circumference centile data also support this conclusion showing general improvements in both weight and in decreased central fatness. Various suggested modifications were made by the families to improve the scheme. These were notably that offering special aerobic or circuit training type classes and more frequent support would be beneficial. The children will be screened for height, weight and therefore BMI by their school nurses a year on from the completion of the project. There are plans to modify the physical activity options and re-run the scheme in another town nearby. Referrals will be sought from the Primary Care Team as well as school nurses and in collaboration with Sure Start. Advice from a statistician will establish a statistically significant sample size. References Cole, T.J. et al. (2000), ‘‘Establishing a standard definition for child overweight and obesity worldwide international survey’’, BMJ, Vol. 320, pp. 1240-53. Health Development Agency (2003), The Management of Obesity and Overweight: An Analysis of Diet, Physical Activity and Behavioural Approaches, Health Development Agency. McCarthy, D. et al. (2003), ‘‘Central overweight and obesity in British Youth aged 11-16 years cross sectional surveys of waist circumference’’, BMJ, Vol. 326, pp. 624. McCarthy, D. et al. (2001), ‘‘The development of waist circumference percentiles in British children aged 5-16.9 years’’, European Journal of Clinical Nutrition, Vol. 55, 902-7. NHS CRD (Centre for reviews and Dissemination) (2002), ‘‘The prevention and treatment of childhood obesity’’, Effective Health Care, Vol. 7 No. 6. SIGN (1996), Obesity in Scotland: Integrating Prevention with Weight Management. A National Clinical Guideline, SIGN, Edinburgh. Further reading Edmund, et al. (n.d), ‘‘Scottish Intercollegiate Guidelines Network (SIGN) Obesity in Scotland: Integrating prevention with weight management’’, Childhood obesity. Anon (2001), ‘‘Evidence based management of childhood obesity’’, BMJ, Vol. 323, 20 October. Gibson, P. et al. (n.d), ‘‘An approach to weight management in children and adolescents (2-18 years) in primary care’’, produced for the Royal College of Paediatrics and Child Health and National Obesity Forum. Prescott-Clarke, P. et al. (1997), Health Survey for England 1995, The Stationery Office, London. Anon (2001), ‘‘School based programmes on obesity’’, BMJ, Vol. 323, 3 November. Third newsletter of All Party Parliamentary Obesity Group www.nationalobesityforum.org.uk Whitaker, R.C. et al. (1997), ‘‘Predicting obesity in young adulthood from childhood and parental obesity’’, N. Engl. J. Med., Vol. 337, pp. 869-73.
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Effects of an over-the-counter herbal weight management product (Zotrim1) on weight and waist circumference in a sample of overweight women: a consumer study
Effects of Zotrim on weight
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C.H.S. Ruxton Nutrition Communications, Cupar, Fife, UK
F. Hinton Edinburgh Dietetic Centre, Edinburgh, UK
C.E.L. Evans Stats and Figures, Leeds, UK Abstract Purpose – Aims to carry out a consumer intervention study to evaluate the impact of an over-thecounter herbal weight management product (Zotrim1 ) on weight and waist circumference. Design/methodology/approach – Overweight women were recruited using local media and 61 passed initial screening to begin a four-week intervention using a free sample of Zotrim at a dosage corresponding to manufacturers’ recommendations. A total of 56 subjects completed the study, but data on all 61 were included in the ‘‘intention to treat’’ analysis. Findings – There was a self-reported mean weight loss of 1.79 kg (0.45 kg per week) at week 4. Data on perceived hunger and fullness from three sets of questionnaires suggested that subjects felt less hungry between meals and fuller after meals at weeks 1 and 4 compared with base-line. This is likely to have impacted on energy intake and may account for the weight loss. Average weight loss as a percentage of baseline was 2.3 per cent, but this masked a broad range, suggesting that some subjects benefited more than others. Taking into account adjusted guidelines for clinically significant weight loss, 23 per cent of subjects achieved this cut-off, suggesting that their risk of chronic disease had reduced. Similarly, waist circumference (an independent measure of disease risk) decreased by an average of 4.3 cm during the four-week period. This reduced the number of subjects exceeding SIGN guidelines for central obesity from 93 per cent to 83 per cent. Originality/value – Adds to the body of knowledge by proring that Zotrim can aid weight loss and help reduce waist circumference. Keywords Obesity, Health education, Medicines, Body regions Paper type Research paper
Introduction Much research has focussed on the aetiology of obesity but relatively little on options for treatment. The Health Committee report (2004) highlighted not only the inadequate resources for weight management offered by the National Health Service, but the shortage of effective, evidence-based options. Systematic reviews of treatment and This study was funded by an educational grant from Natures Remedies Ltd whose employees played no role in the collection or analysis of data.
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prevention programmes (Health Development Agency, 2003; Avenell et al., 2004) suggest that low fat diets are as effective as calorie reduced diets, although the more extreme very low calorie diets (typically less than 1000 kcal per day) induce greater weight loss. Approved drug treatments in the UK are sibutramine and orlistat which can induce a significant weight loss after 12 months (Avenell et al., 2004), although weight seems to increase after this time despite continuation of the drugs (Torgerson et al., 2004). Adding exercise increases the efficacy of diets (Health Development Agency, 2003), while combination programmes of diet, exercise and behavioural therapy appear to give the best weight loss results (Avenell et al., 2003), although the number of published studies is small. Table I summarises mean weight changes and weekly rates of weight loss following various interventions for weight management. While the outcome of these options looks encouraging, albeit modest in terms of weight loss, there are downsides including weight regain (particularly when interventions come to an end), poor compliance, insufficient access to therapies in primary care, and the risk of side effects from drug treatments. Increasing numbers of consumers are now purchasing over-the-counter weight management remedies. However, the scientific evidence for most is sparse (Pittler and Ernst, 2004). One exception is the YGD formulation (now called Zotrim, Natures Remedies) which has been tested in a clinical trial (Anderson and Fogh, 2001) and a consumer study (Ruxton, 2004). Andersen and Fogh randomised 47 healthy overweight subjects to receive either YGD or a placebo. The results demonstrated a statistically significant weight loss of 5.1 kg over the 45-day period (0.8 kg per week) for YGD
Treatment Orlistat (Xenical)
Comparison a
Orlistat (Xenical)b Sibutramine (Reductil)b Low fat or 600 kcal deficit dietb Low calorie dietb Very low calorie dietb Low fat or 600 kcal deficit diet plus exerciseb Diet plus behavioural therapyb Table I. Expected weight loss from obesity treatments
Drug plus lifestyle changes vs placebo plus lifestyle Drug plus diet vs placebo plus diet (mean of 8 studies reported) Drug plus diet vs placebo plus diet (mean of 4 studies reported) Diet vs control (mean of 13 studies reported) Diet vs control (mean of 2 studies reported) Diet vs control (1 study reported) Diet and exercise vs control (mean of 4 studies reported) Diet and behavioural therapy vs control (mean of 3 studies reported)
Notes: a Torgerson et al. (2004); bAvenell et al. (2004)
Weight change at 12 months
Rate of weight loss (kg/week)
10.6 kg with drug vs 6.2 kg for placebo
0.2
5.9 kg with drug vs 3.0 kg with placebo
0.1
5.1 kg with drug vs 0.8 kg with placebo
0.1
4.5 kg with diet vs þ0.6 kg with control 5.7 kg with diet vs +0.4 kg with control 11.1 kg with diet vs +2.3 kg with control 5.9 kg with diet/ex vs +0.8 kg with control
0.1
7.3 kg with diet/ therapy vs +0.6 kg with control
0.1
0.1 0.2 0.1
compared with 0.3 kg for the placebo. No advice on diet or exercise was given to subjects. A follow-up of 22 subjects in the YGD group at 12 month revealed that the initial weight loss was maintained. YGD is likely to induce weight loss by impacting on satiety. A parallel study by Andersen and Fogh (2001) using ultrasound revealed that the rate of gastric emptying in seven volunteers was affected following consumption of YGD vs a placebo. Gastric emptying after YGD was 53 per cent slower than after the placebo. A shorter time to fullness has also been reported by subjects after consuming YGD (Andersen, 2002). The weight loss results of Anderson and Fogh (2001) were supported by previous consumer study (Ruxton, 2004). Forty-eight women given a free trial of Zotrim for 28 days demonstrated a mean weight loss was 2.3 kg (0.6 kg per week). These studies, the clinical and the consumer, provide evidence that the formulation is effective for weight management and can be useful in the field. However, weight on its own is not a good predictor of disease risk. Studies suggest that waist circumference, independent of body mass index (BMI), predicts the risk of chronic diseases such as diabetes and cardio-vascular disease (Zhu et al., 2004; Janssen et al., 2004). Previous studies have not evaluated how Zotrim might impact on measures other than weight and BMI, thus the aim of our study was to look at the effect of one month’s supply of Zotrim on weight, waist circumference and waist-to-hip ratio in free-living subjects. Subjects, recruitment and study design Articles in local newspapers in Fife and Buckinghamshire were used to recruit subjects for a consumer study on weight management. The articles called for overweight women aged over 18 years who were healthy and not currently pregnant or breastfeeding. The study was restricted to women in order to keep the sample as homogenous as possible. The first 115 responding to the articles were sent a recruitment pack, containing an information sheet, a tape measure, screening questionnaire and consent form, by the study dietitian (FH). Exclusion criteria were applied to all women returning the screening questionnaire. There were: BMI below 25 or above 35; poor reported health or multiple medical conditions; reported sensitivity to caffeine; thyroid disease; gastro-intestinal disease; pregnant or breast-feeding; poor motivation or unwillingness to take Zotrim; lack of signature on consent form; being male; aged under 18 years or over 70 years; no access to scales. Women with diabetes mellitus were included but were advised that the risk of hypoglycaemia could increase during the study (if they reduced their consumption of food). The selected sample was sent further instructions and a 4-week supply of Zotrim. Regular telephone calls from the study dietitian were used to prompt subjects to complete the questionnaires at week 1 and week 4, and to take anthropometric measurements at the correct time. Figure 1 gives an overview of the study design. Materials and methods Details of the product Zotrim is a commercially available herbal food supplement containing the active ingredients yerba mate´ (leaves of Ilex paraguayensis), guarana (seeds of Paullinia cupana) and damiana (leaves of Turnera diffusa var. aphrodisiaca). All are extracts of South American herbs which have a history of use in traditional culture. Subjects were asked to take two tablets 15 minutes before meals for seven days. At this point, they were prompted by telephone to increase the dose to three tablets 15 minutes before
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Figure 1. Study design overview
meals for the remainder of the study. These instructions were in line with the manufacturer’s guidance. Anthropometric measurements Subjects were asked to provide weight (kg or lb), height (m or feet), waist circumference (cm) and hip circumference (cm) at Screening. These data were used as the baseline measurements if no changes had occurred between screening and baseline. All measurements were repeated at week 1 and week 4. Full written instructions were given on how to take the measurements and the study dietitian checked comprehension by telephone. Data were converted to metric where necessary.
Questionnaires Four questionnaires were used. The screening questionnaire focussed on information relevant to the exclusion criteria i.e. health related. The baseline questionnaire had three sections: ratings of hunger and fullness around the main meals using a 10 point scale; questions on number and type of snacks consumed; statements on perceived control over eating to which subjects were asked to respond with ‘‘agree’’, ‘‘disagree’’ or ‘‘neutral’’. These three sections were repeated in the questionnaires at week 1 and week 4. Additional questions were added to cover compliance with Zotrim, perceived changes to eating habits and any reported side effects or benefits experienced during the study. Statistical analyses All data were entered into Stata (StataCorp) and analysed. Anthropometric measurements at baseline and at 4 weeks were compared using paired t-tests. Ratings for hunger and fullness were analysed using Wilcoxon Sign Rank tests. Results Subjects and compliance 115 women responded to the media articles and 105 were sent screening questionnaires. Of these, 88 returned their questionnaires and 61 were started on the consumer study with 56 completing all stages. All data from the 61 starters were included to enable an ‘‘intention to treat’’ analysis. Thus, the sample size for the results varies between 56 and 61 depending on the availability of data. Mean baseline weight was 77.9 kg (60.9 kg to 97.7 kg) and mean BMI was 29.4 kg/m2 (25.1 kg/m2 to 35 kg/m2). Mean baseline waist circumference was 93.7 cm (68 cm to 114 cm), while mean waist-to-hip ratio was 0.86 (0.67 to 1.1). 57 women (93 per cent) had a waist circumference in excess of the 80 cm SIGN (1996) guidelines cut-off for central obesity. Reported compliance with Zotrim was good. At week 1, 64 per cent had taken all tablets as instructed and no-one had missed more than a couple of occasions. By week 4, full compliance had gone down to 44 per cent but only 25 per cent had missed more than a couple of occasions. Reasons for lack of compliance included illness, holidays and forgetfulness. Weight and BMI Mean weight loss was 0.7 kg (CI +/0.31) at week 1, and 1.79 kg (CI +/0.65) at week 4, both statistically significant at p < 0.0001 when compared with baseline. The range of weight loss was broad (+2.27 kg to 9.55 kg), suggesting that some subjects responded better than others to the intervention. Figure 2 shows the spread of individual weight change between baseline and week 4. The overall mean rate of weight loss was 0.45 kg per week, although the rate between baseline and week 1 (0.7 kg) was greater than between week 1 and week 4 (0.37 kg). Mean weight loss at week 4 was 2.3 per cent of baseline but this masked a broad range of +2.7 per cent to 12 per cent. Mean BMI reduced by 0.27 at week 1 and by 0.68 by week 4. All changes were statistically significant at p < 0.0001.
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Waist and hip circumferences As Figure 3 shows, mean waist circumference reduced by 1.8 cm at week 1 ( p < 0.001), and by 4.3 cm by week 4, compared with baseline ( p < 0.0001). The range of overall waist circumference change was +3 cm to –11 cm at week 2, and +8 cm to –17 cm at week 4. The reductions brought 10 (17 per cent) subjects below the SIGN guideline cutoff for central obesity. Similar reductions were seen for hip circumference. At week 1, the mean reduction was 1.3 cm ( p < 0.001), while at week 4, it was 3.2 cm ( p < 0.0001). Waist-to-hip ratio remained stable throughout the study at around 0.85. Perceived hunger The 10 point rating scale for reported hunger at mid-morning, mid-afternoon and late evening was collapsed into three groups for ease of analysis. These were scale 1 to 3 ‘‘a little hungry’’, scale four to six ‘‘quite hungry’’, and scale seven to ten ‘‘very hungry’’. Figure 4 shows how hunger mid-morning changed over the study. More women reported feeling less hungry at both week 1 ( p < 0.0001) and week 4 ( p < 0.0001)
Figure 3. Mean change in waist circumference (cm)
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Figure 4. Number of subjects reporting various levels of mid-morning hunger at baseline, week 1 and week 4
compared with baseline. There was no significant difference in hunger between weeks 1 and 4. At the end of the study, 42 women said they were less hungry, eight said they felt the same and 11 said they were more hungry. The median score was five at the beginning of the study, decreasing to three at weeks 1 and 4. There was a similar pattern for the hunger ratings reported for mid-afternoon and late in the evening. Perceived fullness The ten point rating scale for reported fullness after breakfast, after lunch and after the evening meal was collapsed into three groups for ease of analysis. These were scale one to four ‘‘not full’’, scale five to seven ‘‘quite full’’, and scale eight to ten ‘‘very full’’. Figure 5 shows how fullness after lunch changed over the study. More women reported feeling fuller at both week 1 ( p < 0.005) and week 4 ( p < 0.05) compared with baseline. There was no significant difference in hunger between weeks 1 and 4. At the end of the study, 29 women said they were more full, ten said they felt the same and 18 said they were less full after lunch. The median score was seven at the beginning of the study, then eight at both weeks 1 and 4. There was a similar pattern for the hunger ratings reported after breakfast, however, the effect appeared to be greater after the evening meal with 33 women reporting that they were fuller, 12 saying they felt the same and 15 saying they were less full.
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Reported snacking Subjects were asked how many snacks they ate between main meals, and during the evening. Figure 6 shows consumption of snacks following the evening meal. Subjects were more likely to snack in the evening than at any other time with many subjects having two or more snacks. Compared with baseline measures, subjects reported fewer snacks in the evening at week 1 ( p > 0.05) and at week 4 ( p < 0.005). There was no significant change in the number of snacks eaten between weeks 1 and 4. At the end of the study, 25 women said they ate fewer snacks, 28 said they ate the same number and eight said they ate more snacks in the evening. Results were similar for reported snacking between breakfast and lunch, and between lunch and the evening meal. The reductions in snacking at these times of the day were more statistically significant than the evening reductions. Additional perceived effects of Zotrim In order to probe for positive or negative effects associated with taking Zotrim, subjects were asked how they felt at weeks 1 and 4. After a week, 20 subjects reported feeling better, 30 said they felt the same, and 9 said they felt worse. After 4 weeks, the numbers changed to 25 (better), 29 (same) and 5 (worse). Reasons for positive or negative responses were recorded. Subjects could offer more than one explanation. Reasons for a negative response at week 1 (n = 9) and week 4 (n = 5) were feeling unwell or tired, and experiencing a change in bowel habit. Feelings of sleeplessness and bloating were reported by two subjects at week 1, but not week 4. The main reason for a positive response at weeks 1 and 4 was a sense of greater energy (n = 11 both times). Other comments included feeling less hunger and increased well-being, eating more healthily and feeling positive about weight loss (n = 12 at week 1; n = 16 at week 4). Discussion This consumer study demonstrates statistically significant weight loss and changes in body shape over a 4-week period. Subjects were not asked to take a commercially available weight management remedy as per manufacturer’s instructions but not to make any changes to their diet or physical activity regime. While not intended as a scientifically rigorous study, i.e. there was no control group, the work nevertheless fulfils the objective of providing additional evidence in an uncontrolled setting to support the 45-day randomised, placebo-controlled trial of Anderson and Fogh (2001).
Figure 5. Number of subjects reporting various levels of post-lunch fullness at baseline, week 1 and week 4
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Figure 6. Number of subjects reporting snack consumption in the evening at baseline, week 1 and week 4
Although the methodology and duration of the studies differ, it is useful to compare our 28-day study with the results of Anderson and Fogh. Using a one-sample t-test, weight loss in the clinical trial was found to be significantly greater than in the present study. This is an indication that the samples differed and one obvious distinction is the inclusion of men in the clinical trial. A recent study found that men were more successful at losing weight than women (Truby et al., 2004), while another showed that men were better at maintaining resting energy expenditure while dieting (Volek et al., 2004). A second difference is that subjects in the clinical trial were recruited from a weight management clinic (suggesting a commitment to losing weight and perhaps greater dietary knowledge), while those recruited for the consumer study were recruited from the general population. A third difference is the duration – the clinical study was 17 days longer than the consumer study and the rate of weight loss increased from 0.52 kg per week in the first ten days to 0.79 kg per week for the entire study. In contrast, the rate of weight loss in our study decreased from 0.7 kg per week in the first seven days to 0.37 kg per week thereafter. This is more typical of weight management and yet still seems to exceed the rates of weight loss reported for other therapies (0.1 to 0.2 kg per week, see Table I), although it is acknowledged that these studies were conducted over 12 months. Given the changes in reported hunger, satiety and snacking, it is reasonable to assume that the weight changes in our study occurred because subjects were able to eat
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less and maintain this over the 4-week period. It could be assumed that subjects deliberately ate less because they knew they were receiving weight management therapy and being monitored. However, it is interesting to note that the weight change in the placebo group of the Anderson and Fogh clinical study – also a group aware of being monitored and believing that they may have been given an active therapy for weight loss – was only 0.3 kg over 45 days. This suggests that the weight loss in both studies was genuine. While statistically significant weight loss is important, guidelines for weight management place emphasis on the achievement of a clinically significant weight loss, i.e. one that lowers the risk of chronic disease. The National Obesity Forum (NOF, 2004) suggests a figure of 10 per cent of baseline body weight over 12 weeks for clinical significance. When this criterion is applied to our 4-week study, the pro-rata weight loss goal is 3.3 per cent. Fourteen subjects in our study (23 per cent) achieved a weight loss of 3.3 per cent of baseline or more, while a further ten (16 per cent) achieved a weight loss of 2.3 per cent to 3.2 per cent. Only three subjects gained weight over the 4 weeks with a mean gain of 2 kg. The use of Zotrim compares well with conventional therapies such as reduced calorie diets and exercise, particularly since our subjects were not asked to many any changes to either diet or physical activity. Apart from the 12-month studies summarised in Table I, which report an average rate of weight loss of 0.1 kg to 0.2 kg per week, there is evidence from short-term interventions. Drummond et al. (2004) used a 770kcal deficit diet in 76 men and reported a weight loss of 5.2 per cent baseline after 12 weeks (pro rata 1.7 per cent over 4 weeks). This is lower than the 2.3 per cent found in our consumer study. Another study which used a 600kcal deficit diet over 8 weeks in 68 adults reported a mean weight loss of 3.0 kg (pro rata 1.5 kg over 4 weeks). This, again, is lower than the 1.79 kg found in our consumer study. A key component of this study was to evaluate how Zotrim impacted on waist circumference, since this is an independent determinant of disease risk. Mean waist reduction was 4.3 cm which lowered the proportion of women exceeding the SIGN (1996) cut-off for central obesity from 93 per cent at baseline to 83 per cent at 4 weeks. The reduction in waist circumference compared well with that reported by other studies. Wien et al. (2004) achieved a 14 per cent reduction in waist circumference over 24 weeks in 65 adults using a low calorie formula diet enriched with almonds. The pro rata reduction of 2.3 per cent over 4 weeks is lower than the 4.5 per cent reduction in waist circumference seen in our study. Similarly, a 6-week high carbohydrate dietary intervention in 63 men achieved a 2.6 cm (2.7 per cent) reduction in waist circumference (Archer et al., 2003), while a 12-week energy restricted dietary intervention in 51 men achieved a 8.1 cm reduction in waist circumference (Ash et al., 2003). The pro rata reductions in these two studies would be 1.7 cm and 2.7 cm respectively, compared with the 4.3 cm in our study. Zotrim appeared to have a greater impact on waist circumference than the therapies reported in these studies. Conclusion This consumer study provides further evidence that an over-the-counter herbal weight management product (Zotrim) can help induce a statistically significant mean weight loss in a sample of overweight free-living women. The product also had
a significant impact on waist circumference, an independent determinant of chronic disease risk. Both the weight and waist circumference changes over 4 weeks compare favourably with longer-term conventional weight management therapies. References Andersen, T. and Fogh, J. (2001), ‘‘Weight loss and delayed gastric emptying following a South American herbal preparation in overweight patients’’, Journal of Human Nutrition and Dietetics, Vol. 14, pp. 243-50. Archer, W.R., Lamarche, B., Deriaz, O., Landry, N., Corneau, L., Despres, J.P., Bergeron, J., Couture, P. and Bergeron, N. (2003), ‘‘Variations in body composition and plasma lipids in response to a high-carbohydrate diet’’, Obesity Research, Vol. 11, pp. 978-86. Ash, S., Reeves, M.M., Yeo, S., Morrison, G., Carey, D. and Capra, S. (2003), ‘‘Effect of intensive dietetic interventions on weight and glycaemic control in overweight men with Type II diabetes: a randomised trial’’, International Journal of Obesity, Vol. 27, pp. 797-802. Avenell, A., Broom, J., Brown, T.J., Poobalan, A. et al. (2004), ‘‘Systematic review of the long-term effects and economic consequences of treatments for obesity and implications for health improvement’’, Health Technology Assessment, Vol. 8 No. 21. Drummond, S., Dixon, K., Griffin, J. and De Looy, A. (2004), ‘‘Weight loss on an energy-restricted, low-fat, sugar-containing diet in overweight sedentary men’’, International Journal of Food Sciences and Nutrition, Vol. 55, pp. 279-90. Health Development Agency (2003), ‘‘The management of obesity and overweight’’, An Analysis of Reviews of Diet, Physical Activity and Behavioural Approaches, HDA, London. House of Commons, Health Committee (2004), Obesity, Third report of session 2003-04, Vol. 1, The Stationery Office, London. Janssen, I., Katzmarzyk, P.T. and Ross, R. (2004), ‘‘Waist circumference and not body mass index explains obesity-related health risk’’, American Journal of Clinical Nutrition, Vol. 79, pp. 379-84. National Obesity Forum (2004), Guidelines for Management of Adult Obesity and Overweight in Primary Care, National Obesity Forum, London, available at: www. nationalobesityforum.org.uk/ Pittler, M.H. and Ernst, E. (2004), ‘‘Dietary supplements for body-weight reduction: a systematic review’’, American Journal of Clinical Nutrition, Vol. 79, pp. 529-36. Torgerson, J.S., Boldrin, M.N., Hauptman, J., Sjo¨stro¨m, L. (2004), ‘‘XENical in the prevention of diabetes in obese subjects (XENDOS) study’’, Diabetes Care, Vol. 27, pp. 155-61. Truby, H., Millward, D., Morgan, L., Fox, K., Livingstone, M.B., DeLooy, A. and Macdonald, I. (2004), ‘‘A randomised controlled trial of 4 different commercial weight loss programmes in the UK in obese adults: body composition changes over six months’’, Asia Pacific Journal of Clinical Nutrition, Vol. 13(Suppl), pp. S146. Ruxton, C.H.S. (2004), ‘‘Efficacy of Zotrim: a herbal weight loss preparation’’, Nutrition & Food Science, Vol. 34, pp. 25-28. Volek, J.S., Sharman, M.J., Gomez, A.L., Judelson, D.A., Rubin, M.R., Watson, G., Sokmen, B., Silvestre, R., French, D.N. and Kraemer, W.J. (2004), ‘‘Comparison of energy-restricted very low-carbohydrate and low-fat diets on weight loss and body composition in overweight men and women Nutritional Metabolism’’, Vol. 1 No. 1, pp. 13.
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Wien, M.A., Sabate, J.M., Ikle, D.N., Cole, S.E. and Kandeel, F.R. (2004), ‘‘Almonds vs complex carbohydrates in a weight reduction program’’, International Journal of Obesity, Vol. 27, pp. 1365-72. Zhu, S., Heshka, S., Wang, Z., Shen, W., Allison, D.B., Ross, R. and Heymsfield, S.B. (2004), ‘‘Combination of BMI and waist circumference for identifying cardiovascular risk factors in whites’’, Obesity Research, Vol. 12, pp. 633-45. Further reading Scottish Intercollegiate Guidelines Network (SIGN) (1996), Obesity in Scotland. Integrating Prevention with Weight Management, publication No. 8, SIGN, Edinburgh. West, J.A., de Looy, A.E. (2001), ‘‘Weight loss in overweight subjects following low-sucrose or sucrose-containing diets’’, International Journal of Obesity, Vol. 25, pp. 1122-8.
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Predictors of physician overweight and obesity in the USA: an empiric analysis John La Puma
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Director, Santa Barbara Institute for Medical Nutrition and Healthy Weight, Santa Barbara, California, USA
Philippe Szapary Assistant Professor of Medicine, Division of General Internal Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
Kevin C. Maki President and CEO, Provident Clinical Research and Consulting, Wheaton, Illinois, USA Abstract Purpose – Because patients are more likely to follow advice from healthy weight rather than overweight physicians, seeks to determine whether physician overweight could be predicted by selfreported physician eating behaviors. Design methodology/approach – An anonymous, written, self-administered, pre-tested, confidential survey of practicing physicians in the Midwestern USA was undertaken. Findings – Most surveyed physicians (394 or 74 per cent) completed the survey. The results indicate that stress at home (OR 2.62, CI 1.35-5.08) was most significantly and strongly predictive of physician overweight (BMI > 25 kg/m2), as were particular eating behaviors, including eating food provided at the medical office. Assessment of overall health was significantly and strongly inversely proportionally predictive (OR 0.43, CI 0.30-0.62) of physician overweight as well. Research limitations/implications – The research implies that, like patients, practicing US physicians are susceptible to feelings other than hunger which prompt over-eating and weight gain. Limitations include study of a single, specific sample of physicians, and an exclusive focus on food and nutrition. Future research may wish to include measures of fitness and exercise. Originality/value – Physicians are susceptible to predictable, particular feelings other than hunger which prompt over-eating and overweight. Physician ability to respond to these feelings and to ameliorate the stresses and factors associated with them may help improve physician overweight and, in turn, physician ability to facilitate patient weight loss. Keywords Diet, Nutrition, Doctors, Obesity, Health education, Stress Paper type Viewpoint
Background McMenamin et al. report that nutrition programs are the second most prevalent health promotion intervention offered to physicians McMenamin et al. (2004), and attention Disclosures: Dr La Puma has received compensation from 1999-2004 for consulting with medical conference sponsors to create and supervise healthful conference meals. Dr Maki has received honoraria, research stipends and/or consulting fees related to products or research on weight management from: Roche Pharmaceuticals, Ross Products Division of Abbott Laboratories, Kao Corporation, Glanbia Foods, AMBI Corporation and General Mills. Dr Szapary has nothing to declare. Presented at the 4th Annual University of Chicago Conference on Alternative Medicine, Chicago, Illinois, December 13, 2002. Versions of this work have not been previously published; it is part of the CHEF Clinic study, and its other published studies are referenced.
Nutrition & Food Science Vol. 35 No. 5, 2005 pp. 315-319 # Emerald Group Publishing Limited 0034-6659 DOI 10.1108/00346650510625502
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has been drawn to physicians’ own lifestyle and work habits with the rising prevalence of obesity Young (2004). As part of a study of physician overweight, we wondered whether certain behavioral factors are associated with physician overweight. Methods We conducted a descriptive, cross-sectional pilot study using an anonymous mailed, pre-tested, confidential questionnaire of a large, suburban, community, non-teaching Midwestern hospital in Fall 2001. We surveyed the entire active, current medical staff (MD or DO degree), totaling 538; 2 questionnaires could not be delivered. Using a 5point scale, using both Likert scales and multiple choice questions, we asked how often respondents ate while talking on the phone, reading or working at a computer, and watching television. We asked whether physicians often ate while lonely or bored; for pleasure using food as a reward; to help deal with stresses at home or work; when in a social situation; or while drinking alcohol (see Table I). The protocol and pilot instrument, derived from behavior modification literature Foreyt and Goodrick (1993) and the investigators’ clinical experience, were designated as exempt research by the institution’s IRB. Characteristics of the study sample categorized according to BMI (30 kg/m2). The Table shows both univariate and multivariate behavioral predictors of overweight and obesity. In our multivariate analysis, adjusted for age, race/ethnicity, and gender, several self-reported behaviors were identified associated with overweight/ obesity. Greater self-rated overall health was strongly inversely associated with overweight/obesity [0.39 (0.26-0.57)] using data collapsed into a three point ordinal scale (poor/fair = 1, good = 2, very good/excellent = 3). Other reported eating behaviors, such as eating while talking on the phone, and working on a computer were not significantly related as predictors of overweight; neither was likelihood of overeating when in a social situation or when drinking alcohol. Discussion These data suggest that certain lifestyle and work factors may be associated with self-reported overweight in a population of US practicing physicians. Two factors concern self-reported stress. There is evidence that ‘‘stress-eaters’’ in the general population are more likely to be overweight than those who are not so identified Laitinen et al. (2002). Basic science research now links chronic stress and obesity Dallman et al. (2003). Abdominally obese people with metabolic syndrome have
Univariate analysis
Adjusted for age, race and sex
Odds ratioa
95% C.I.
Odds ratioa
95% C.I.
91 (23.1) 36 (16.4) 55 (31.6)
2.36
1.46, 3.82
2.65
1.57, 4.47
All physicians BMI
