The criterion validity of a last 7-day physical activity questionnaire (SAPAQ) for use in adolescents with a wide variation in body fat: the Stockholm Weight Development Study

OBJECTIVE

The aim of the present study was to assess the criterion validity of a newly developed self-reported last 7-day physical activity questionnaire (SAPAQ) for use in Swedish adolescents with a wide variation in body fatness.

MEASUREMENTS

We compared the self-reported total number of MET-minutes with objectively assessed variables of physical activity obtained by accelerometry in 49 (18 male, 31 female subjects) 17-year-old adolescents.

RESULTS

Self-reported physical activity was significantly and inversely related to time spent sedentary (r=-0.45; P<0.001) and significantly and positively associated with time spent in physical activity (r=0.51; P<0.001) and the total amount of physical activity (r=0.49; P<0.001). Gender and body fat did not affect the associations between self-reported and objectively assessed physical activity.

CONCLUSION

Our results indicate that the newly developed questionnaire is a valid method for ranking individuals in terms of the total amount of physical activity in Swedish adolescents.

Randomized, multi-center trial of two hypo-energetic diets in obese subjects: high- versus low-fat content

OBJECTIVE

To investigate whether a hypo-energetic low-fat diet is superior to a hypo-energetic high-fat diet for the treatment of obesity.

DESIGN

Open-label, 10-week dietary intervention comparing two hypo-energetic (-600 kcal/day) diets with a fat energy percent of 20-25 or 40-45.

SUBJECTS

Obese (BMI >or=30 kg/m(2)) adult subjects (n = 771), from eight European centers.

MEASUREMENTS

Body weight loss, dropout rates, proportion of subjects who lost more than 10% of initial body weight, blood lipid profile, insulin and glucose.

RESULTS

The dietary fat energy percent was 25% in the low-fat group and 40% in the high-fat group (mean difference: 16 (95% confidence interval (CI) 15-17)%). Average weight loss was 6.9 kg in the low-fat group and 6.6 kg in the high-fat group (mean difference: 0.3 (95% CI -0.2 to 0.8) kg). Dropout was 13.6% (n = 53) in the low-fat group and 18.3% (n = 70) in the high-fat group (P=0.001). Among completers, more subjects lost >10% in the low-fat group than in the high-fat group ((20.8%, n = 70) versus (14.7%, n = 46), P = 0.02). Fasting plasma total, low-density lipoprotein- and high-density lipoprotein-cholesterol decreased in both groups, but more so in the low-fat group than in the high-fat group. Fasting plasma insulin and glucose were lowered equally by both diets.

CONCLUSIONS

The low-fat diet produced similar mean weight loss as the high-fat diet, but resulted in more subjects losing >10% of initial body weight and fewer dropouts. Both diets produced favorable changes in fasting blood lipids, insulin and glucose.

Effect of three treatment schedules of recombinant methionyl human leptin on body weight in obese adults: a randomized, placebo-controlled trial

AIM

The aim of this study was to evaluate the effect on body weight and safety of subcutaneously administered recombinant leptin in obese adults and to evaluate whether the timing of recombinant leptin administration influences efficacy.

METHODS

A randomized, double-blind, placebo-controlled, multicentre study was designed, comprising of a 3-week dietary lead-in followed by a 12-week leptin or placebo treatment period. A total of 284 overweight and obese (body mass index 27-37.0 kg/m(2)) predominantly white (98%) women (66%) and men (34%) with a mean (+/-s.d.) 46.8+/-10.4 years of age were randomized into three treatment groups with three matching placebo groups. Recombinant leptin was administered by subcutaneous injection [10 mg/morning, 10 mg/evening or 20 mg/day (10 mg twice daily)]. Patients were counselled at baseline to reduce dietary intake by 2,100 kJ/day (500 kcal/day), and dietary advice was reinforced every 2-4 weeks.

RESULTS

No statistically significant change in body weight occurred with recombinant leptin treatment compared with placebo treatment in any treatment group. No clinically significant adverse effects were observed with the exception of an increase in injection-site reactions in patients treated with recombinant leptin (83%) vs. placebo (36%).

CONCLUSIONS

Administration of recombinant leptin to an overweight and obese population, in addition to a mildly energy-restricted diet, was not efficacious in terms of weight loss at the doses and schedules studied. The hypothesis that nocturnal administration of recombinant leptin might have a specific effect on weight loss was not supported.

Who succeeds in maintaining weight loss? A conceptual review of factors associated with weight loss maintenance and weight regain

Weight loss is difficult to achieve and maintaining the weight loss is an even greater challenge. The identification of factors associated with weight loss maintenance can enhance our understanding for the behaviours and prerequisites that are crucial in sustaining a lowered body weight. In this paper we have reviewed the literature on factors associated with weight loss maintenance and weight regain. We have used a definition of weight maintenance implying intentional weight loss that has subsequently been maintained for at least 6 months. According to our review, successful weight maintenance is associated with more initial weight loss, reaching a self-determined goal weight, having a physically active lifestyle, a regular meal rhythm including breakfast and healthier eating, control of over-eating and self-monitoring of behaviours. Weight maintenance is further associated with an internal motivation to lose weight, social support, better coping strategies and ability to handle life stress, self-efficacy, autonomy, assuming responsibility in life, and overall more psychological strength and stability. Factors that may pose a risk for weight regain include a history of weight cycling, disinhibited eating, binge eating, more hunger, eating in response to negative emotions and stress, and more passive reactions to problems.

Discrepancies between classification systems of childhood obesity

Despite growing concern about weight-related problems among children, no universally accepted classification system for childhood obesity exists. There is a number of proposed international body mass index (BMI)-based systems in use and national variants also exist in many countries. The absence of a universally accepted standard and confusion concerning which classification system to use on national levels complicate monitoring of the development of the obesity epidemic, stratification for selective interventions in public health, screening in clinical practice and comparisons between studies. Some proposed international classification systems have not only been recommended for global monitoring and comparisons between studies, but also for clinical and national epidemiological use in some countries. Possible discrepancies may thereby lead to inefficiencies in health care delivery and prevention programmes. The problems associated with misclassification of individuals at risk may lead to overconsumption of health care resources by lower-risk individuals and underconsumption by higher-risk individuals, which is costly both in terms of foregone health improvements and in terms of wasteful monetary usage. The aim of this paper was to review the specific problems associated with BMI as a measure of adiposity in childhood, the most commonly used classification systems for childhood obesity based on BMI, and how their performance can be evaluated.

Degree of body weight in obesity and Rorschach personality aspects of mental distress

OBJECTIVE

To study the relationship between degree of obesity and personality measures of mental distress.

METHOD

The Rorschach method (Comprehensive System) and the Beck Depression Inventory. General descriptors were also included. Participants were 120 obese patients with a mean body mass index (BMI) of 41 (+/- SD 6) kg/m2.

RESULTS

Depression, stress or psychopathology such as distortions in perception and cognitions were not related to the degree of obesity. Body concern and body-related anxiety (An+Xy) were more common in relatively lower degrees of obesity. According to general descriptors heavier patients had lower educational and socio-economic level, and more bodily pain problems.

DISCUSSION

Depression was not related to body weight, in spite of findings of more depression in obesity compared to normal weights. Other factors than severity of obesity would account for the mental distress in obese patients. The differences in body concern and anxiety in varying degrees of obesity could be related to the social and educational context, where attitudes toward obesity differ. Less Rorschach signs of body concern in the morbidly obese contrasted with more self-reported bodily pain problems.

Weight development over time in parous women--the SPAWN study--15 years follow-up

BACKGROUND

Weight gain is common after pregnancy. Most studies suggest that weight gain associated with a pregnancy is between 0.5 and 3.8 kg up to 2.5 y of follow-up. However, 73% of the female patients at our obesity clinic identified pregnancy as an important trigger for marked weight retention. The majority retained more than 10 kg after each pregnancy. The aim of this study was to examine long-term weight development after pregnancy in a 15 y follow-up of women who took part in the Stockholm Pregnancy And Women's Nutrition (SPAWN) study.

METHOD AND SUBJECTS

The SPAWN study is a long-term follow-up study of women who delivered children in 1984-85 in Stockholm (n=2342). A total of 1423 participants (response rate=61%) completed questionnaires, which covered eating behaviour and exercise, demographic information including social situation and status and details of the pregnancy before, during and up to 1 y after pregnancy. After 15 y, these women were invited to take part in the follow-up study. Anthropometric measurements and the same questionnaire data were collected from the 563 women who participated (response rate=40%). The sample was divided into two main groups: those who were normal weight before pregnancy and remained normal weight, and those who were normal weight before pregnancy and had become overweight at 15 y follow-up.

RESULTS

Those women who became overweight had a higher pre-pregnant body mass index (BMI) (22.3+/-1.5 vs 20.5+/-1.6 kg/m(2), P<0.001), gained more weight during pregnancy (16.3+/-4.3 vs 13.6+/-3.7 kg, P<0.001) and had retained more at 1 y follow-up. The women who became overweight had a steeper weight trajectory gaining more from 1 y follow-up to 15 y follow-up (11.1+/-6.5 vs 4.5+/-6.5 kg, P<0.001), with a higher BMI at 15 y follow-up of 27.5+/-2.6 vs 22.5+/-2.3 5 kg/m(2) (P<0.001). However, differences between those who became overweight and those who did not could not be explained by age, number of children and various socioeconomic factors. Features of pregnancy that did differ between the two groups were breastfeeding and smoking cessation. However, women who became overweight had lower lactation scores than women who remained normal weight. Relatively more subjects of the group that became overweight stopped smoking during pregnancy.

DISCUSSION

Pregnancy is a vulnerability factor for some women to become overweight. This study attempted to identify those factors that place initially normal weight women on a steeper weight trajectory as a result of pregnancy. Demographic, behavioural, physical and psychological characteristics only partly explain the weight gain observed at 15 y follow-up. Further research is required to investigate the relative role of these characteristics in predicting postpregnancy weight development.

Success rate of Orlistat in primary-care practice is limited by failure to follow prescribing recommendations: the referral letter content vs clinical reality

Numerous referrals to our Obesity Unit state that 'treatment with Orlistat did not work'. This surprised us, since Orlistat has been well documented to result in long-term sustained moderate weight loss. A simple questionnaire to 70 such patients, however, revealed that in many cases the referral physician had not observed basic rules and regulations, nor given appropriate information on Orlistat use.

Short-term effects of sibutramine (Reductil) on appetite and eating behaviour and the long-term therapeutic outcome

OBJECTIVE

To evaluate the short-term effects of sibutramine on appetite and eating behaviour and whether these effects are related to the long-term therapeutic outcome.

STUDY DESIGN

Short-term: randomised, double-blind, placebo-controlled, within-subject design. Long-term: prospective open clinical trial.

SUBJECTS

A total of 36 obese (nine men/27 women) with a body mass index of 39.3+/-4.3 (mean+/-s.d.) (range 30.2 - 45.2) kg/m(2) and age 44.4+/-12.1 y. PROCEDURE AND METHODS:: First phase-short-term effects: At baseline, the subjects were treated for 14 days with 15 mg sibutramine/placebo (period 1) followed by a 2 weeks single-blind placebo washout period, the subjects received the alternative therapy for another 14 days (period 2). At baseline, and at day 14 in each treatment period the subjects arrived fasting to the laboratory for a standardised breakfast and an ad libitum standardised lunch using the VIKTOR set-up (a universal eating monitor) to evaluate the microstructure of the eating behaviour (ie amount of food consumed and eating rate). Visual Analogue Scales were applied before and after the meals as well as every hour between the meals to monitor the appetite. During this first phase, subjects were encouraged to keep their habitual eating habits. Second phase-long-term effects: All subjects received 10 months open treatment with 15 mg sibutramine and dietary advice in monthly group sessions with a dietitian. On the last day of this treatment period, the subjects returned to repeat the measurements of appetite and eating behaviour using the same test procedure as during the first phase of the study.

RESULTS

First phase: Sibutramine influenced appetite and eating behaviour that could be registered after only 14 days of treatment. The amount of food consumed at lunch on VIKTOR was reduced by 16% by sibutramine compared to placebo, 335+/-123 g vs 399+/-126 g (P<0.0001). Second phase: Responders and nonresponders were defined as those who ate less vs more food on VIKTOR when treated with sibutramine compared to the baseline food intake in the first phase of the study. The weight reduction was greater for responders 11.8+/-6.2 (mean+/-s.d.) kg compared to nonresponders 6.8+/-2.7 (mean+/-s.d.) kg (P<0.05).

CONCLUSION

Short-term effects of sibutramine on appetite and eating behaviour were identified such as a reduction in food intake and in ratings of subjective motivation to eat. Short-term sibutramine effects on eating behaviour are to some extent related to the long-term therapeutic outcome in obese subjects.

Effects of glucocorticoids on leptin levels and eating behaviour in women

OBJECTIVE

Long-term treatment with glucocorticoids induces weight gain and increased risk to develop obesity-related metabolic complications. The underlying mechanisms are not fully understood. Glucocorticoid therapy has previously been associated with increased levels of circulating leptin. In this study the eating behaviour was therefore studied in relation to leptin levels before and after short-term prednisolone treatment.

DESIGN

Within-subject design.

SUBJECTS

Twelve healthy postmenopausal women with a mean body mass index (BMI) of 28.9 kg m-2 (+/-0.8 SEM) volunteered after recruitment by an advertisement in the local paper.

INTERVENTIONS

The subjects received 25 mg prednisolone daily for 7 days.

MAIN OUTCOME MEASUREMENTS

Fasting serum samples were obtained before, during and after treatment for determination of leptin and insulin, glucose and fractionated lipoproteins in plasma. The microstructure of the eating behaviour was registered with a universal eating monitor, VIKTOR. Appetite was estimated by visual analogue rating scales and food intake by a 48-h recall.

RESULTS

Serum leptin increased after 2 and 7 days of glucocorticoid administration (P < 0.01), and the food intake measured by VIKTOR after 7 days of treatment (P < 0.05). No statistically significant changes were however, found in the 48-h food- recall or in the subjective appetite registrations. Insulin levels were borderline elevated (P = 0.062) after treatment, but no significant changes of fasting glucose were seen. High density lipoprotein cholesterol (HDL) increased (P < 0.05), whilst low density lipoprotein cholesterol (LDL) decreased (P < 0.05).

CONCLUSION

Food intake was elevated after glucocorticoid administration as observed with an objective, quantitative method, in spite of increased levels of circulating leptin.

Predictive value of early weight loss in obesity management with orlistat: an evidence-based assessment of prescribing guidelines

OBJECTIVE

To assess the clinical usefulness of published guidelines for the use of orlistat, by studying whether weight loss >/=2.5 kg during a 4 week dietary lead-in period, and weight losses of >/=5% after 12 weeks and >/=10% after 6 months of drug therapy predict weight loss and risk factor changes after 2 years.

DESIGN

A retrospective analysis of pooled data from 2 multicentre, randomised, placebo-controlled clinical trials with similar design.

SETTING

Twenty-nine centres throughout Europe.

PARTICIPANTS

Two hundred and twenty men and women (BMI 28-43 kg/m(2)) who completed 2 years of treatment.

INTERVENTION

After a 4 week hypocaloric diet plus placebo, 2 years of treatment with orlistat 120 mg tid, plus a hypocaloric diet for the first year and a weight maintenance diet in year two.

MAIN OUTCOME MEASURES

Weight loss and obesity-related risk factor changes.

RESULTS

Weight loss >/=5% body weight after 12 weeks of diet plus orlistat therapy was a good indicator of 2 year weight loss, whereas weight loss of >/=2.5 kg during the 4 week lead-in and >/=10% after 6 months did not add significantly to the prediction of 2 year outcomes. Patients who lost >/=5% of their weight at 12 weeks (n=104, 47.3%) lost significantly more weight after 2 years than others: -11.9% (95% confidence interval (CI) -13.4% to -10.3%) vs -4.7% (-5.7% to -3.7%) (P=0.0001), and had significantly greater reductions in total cholesterol, LDL-cholesterol, triglycerides, glucose, insulin, and blood pressure. Among those who achieved >/=5% weight loss at 12 weeks, the overall health benefits were not significantly greater in patients who went on to lose >/=10% body weight at 6 months compared with those who did not achieve >/=10% weight loss by month 6.

CONCLUSIONS

Of the criteria currently suggested for assessing response to orlistat treatment, weight loss of >/=5% at 12 weeks accurately predicts sustained improvements in weight and major risk factors at 2 years, while other suggested criteria are less useful.

Obesity: the disease of the twenty-first century

The prevalence of obesity is increasing globally, with nearly half a billion of the world's population now considered to be overweight or obese. The obesity epidemic is related both to dietary factors and to an increasingly sedentary lifestyle. Obesity has significant co-morbidities and these are associated with substantial health care and social costs. Of particular concern is the fact that obesity is increasing among children and adolescents. National health policymakers must take action to deal with the obesity problem. Prevention should be the primary target, but it is also important to develop strategies to treat those already affected with obesity.

Intake of sweet foods and counts of cariogenic microorganisms in relation to body mass index and psychometric variables in women

OBJECTIVE

As a part of the SPAWN (Stockholm Pregnancy and Women's Nutrition) study, the intake of sweet foods (habitual and pre-menstrual intakes) and the number of cariogenic microorganisms in saliva was analysed in relation to body mass index (BMI) and psychometric variables.

DESIGN

A cross-sectional study.

SUBJECTS

Three hundred and sixty-two women with a median BMI of 24.2 kg/m(2) (range 17.5-47.8) and 45 y of age (range 34-64).

METHODS

A questionnaire of sweet food intake, salivary counts of mutans streptococci and lactobacilli and a self-rating scale on psychometric variables (CPRS-S-A).

RESULTS

The number of mutans streptococci correlated with BMI (P<0.05), indirectly indicating a higher intake of sweet foods in obese women. The reported energy intake of sweet foods (more specifically the intake of chocolate), correlated with CPRS scores (P<0.01), indicating that women with more severe psychiatric symptomatology have higher intakes of sweet foods.

CONCLUSIONS

This study suggests that women with higher CPRS score have higher energy intakes of sweet foods, indicating a possible link between mood regulation and the intake of sweet food.

SPONSORSHIP

Karolinska Institute Research Funds.

Insulin signal transduction and glucose transport in human adipocytes: effects of obesity and low calorie diet

AIM/HYPOTHESIS

We examined insulin signal transduction at the level of insulin receptor substrates (IRS) 1 and 2, phosphatidylinositol (PI) 3-kinase and glucose transport in isolated subcutaneous adipocytes from obese and lean women.

METHODS

Glucose transport and insulin signalling were investigated in isolated adipocytes from six obese women (BMI 36-43 kg/m(2)) (before and after 11 days of very low calorie diet) and from six lean women (BMI 22-26 kg/m(2)).

RESULTS

Insulin sensitivity of glucose transport was reduced in adipocytes from obese women (p<0.05), with further reductions in basal and maximal insulin-stimulated glucose transport after a very low calorie diet (p<0.05). In obese women, IRS-1 associated PI 3-kinase activity was markedly impaired (p<0.05), whereas, IRS-2 associated PI 3-kinase activity was normal. IRS-1 associated PI 3-kinase activity remained blunted after a very low calorie diet, whereas IRS-2 associated PI 3-kinase activity was increased. GLUT4 protein was reduced by 37% in obese versus lean subjects (p<0.05), and decreased further after a very low calorie diet (from 19+/-4 to 14+/-4 arbitrary units; p<0.05).

CONCLUSION/INTERPRETATION

IRS-1 signalling to PI 3-kinase is a site of insulin resistance in adipocytes from obese women, whereas insulin action on IRS-2 is normal. Thus, IRS-1 and IRS-2 undergo differential regulation in adipocytes from obese insulin resistant subjects. Finally, a very low calorie diet is associated with a further impairment in glucose transport in adipose tissue. The defect in glucose transport after a very low calorie diet occurs independent of further defects in insulin signalling at the level of the PI 3-kinase.

Long-term weight development after pregnancy

For some women pregnancy is a trigger for developing overweight and obesity. Seventy-three per cent of 128 female patients at our Obesity Unit indicated that they had retained more than 10 kg after each of their pregnancies, and for this subgroup weight development after pregnancy was of crucial importance for their future health. Although mean weight increases after pregnancy generally are modest, there are wide individual variations. In studies at the Obesity Unit, weight retention ranging from up to 26.5 kg one year after pregnancy to a loss of 12.3 kg was reported, although the mean weight gained was only 0.5 kg. Numerous studies have analysed factors explaining weight development after pregnancy and delivery, with a range of subjects from several hundred thousand women to fewer than one-hundred, but overall it has been surprisingly difficult to identify strong predictors of weight development. Numerous confounders have been identified; in a review up to 31 such confounders were reported. Methodological problems include weight development over time also in non-pregnant women and problems of identifying the optimal time-point when the overall impact of the pregnancy on weight development should be evaluated. Lactation has consistently been found to play a small role in explaining weight retention up to one year after delivery. Few studies have examined the role of physical activity during pregnancy and after delivery to explain weight development. Our own ongoing follow-up of women who gave birth during 1984-85, the so-called SPAWN (Stockholm Pregnancy and Women's Nutrition) study, illustrates that 15 years after delivery, a significant proportion of the 1423 women initially studied were available for re-examination. Drop-out analyses indicate that for most variables under study, the remaining women were representative for the initial sample. Pregnancy and weight development are intertwined in a complex pattern, which includes a change in lifestyle factors, such as eating behaviour, physical activity, smoking cessation and degree of lactation, but which are still not fully understood.

Patient expectations of obesity treatment-the experience from a day-care unit

BACKGROUND

Unrealistic patient weight loss expectations in treatment of obesity may hamper the modest success which can actually be achieved.

SETTING

Academic Obesity Unit Day Care Centre.

OBJECTIVE

Description of weight loss expectations and weight loss concerns by questionnaire analyses.

RESULTS

Patients were severely obese, with a median initial body mass index (BMI) of 40.7 kg/m(2). Weight loss expectations were generally unrealistic, with women hoping for a loss up to 42%, and men for 29% of their baseline weight (P<0.001). No effects of age on actual weight loss or weight loss expectations were observed.

CONCLUSION

Gender differences in weight loss expectations may be important to acknowledge in future development of obesity treatment programmes. Realistic treatment outcome should be described early in a programme to facilitate compliance.

["Consolatory eating" is not a myth. Stress-induced increased cortisol levels result in leptin-resistant obesity]

Recent studies indicate that stress induces increased food intake only when stress is followed by a neuroendocrine reaction with increased cortisol concentrations. The stress of modern society may contribute to the current epidemic of abdominal obesity, which is characterised by increases in cortisol and leptin concentrations. This is a condition which carries a great risk for cardiovascular disease, type 2 diabetes mellitus and stroke.