Population-based prevention of obesity: the need for comprehensive promotion of healthful eating, physical activity, and energy balance: a scientific statement from American Heart Association Council on Epidemiology and Prevention, Interdisciplinary Committee for Prevention (formerly the expert panel on population and prevention science)

Association between the French nutritional guideline-based score and 6-year anthropometric changes in a French middle-aged adult cohort

In light of increasing obesity among the elderly, understanding the role of nutritional guidelines in preventing weight gain is of major importance. The authors evaluated the impact of the French Programme National Nutrition Santé (PNNS)-Guideline Score (GS) (maximum score, 15 points) on anthropometric changes in a large population-based study. Subjects in the present analysis (n = 3,531) were participants in the SUplémentation en VItamines et Minéraux AntioXydants (SU.VI.MAX) study (1994-2002) and had available data for estimating the PNNS-GS and anthropometric data at baseline and 6 years later. Data were analyzed by using multivariate linear regression models for the association with anthropometric changes and multiple logistic regression to estimate odds ratios of becoming overweight or obese. The authors found a significant negative association between PNNS-GS and changes in markers of anthropometry. In addition, better adherence to the PNNS-GS was associated with a lower incidence of overweight (odds ratio = 0.93, 95% confidence interval: 0.88, 0.99) and obesity (odds ratio = 0.89, 95% confidence interval: 0.80, 0.99) after a 6-year follow-up period. These observations support the role of nutritional guidelines in prevention of age-related weight increase and development of obesity.

Cardiac health: primary prevention of heart disease in women

Heart disease is the number one cause of death among women. Although 450,000 women die annually from heart disease, this fact is unknown to many women. Because heart disease is frequently preventable, increasing awareness of personal risk and preventative measures is a key element of health care for women. Nurse clinicians can evaluate, educate, and counsel women regarding their risk for this pervasive disease and promote behavior changes that will decrease that risk. Research evidence supports that lifestyle behaviors are the cornerstone of heart disease prevention. This article presents current evidence for the prevention of heart disease related to dietary intake, physical activity, weight management, smoking cessation, blood pressure control, and lipid management. Guidelines for implementing findings in clinical practice are discussed.

Dietary sugars intake and cardiovascular health: a scientific statement from the American Heart Association

High intakes of dietary sugars in the setting of a worldwide pandemic of obesity and cardiovascular disease have heightened concerns about the adverse effects of excessive consumption of sugars. In 2001 to 2004, the usual intake of added sugars for Americans was 22.2 teaspoons per day (355 calories per day). Between 1970 and 2005, average annual availability of sugars/added sugars increased by 19%, which added 76 calories to Americans' average daily energy intake. Soft drinks and other sugar-sweetened beverages are the primary source of added sugars in Americans' diets. Excessive consumption of sugars has been linked with several metabolic abnormalities and adverse health conditions, as well as shortfalls of essential nutrients. Although trial data are limited, evidence from observational studies indicates that a higher intake of soft drinks is associated with greater energy intake, higher body weight, and lower intake of essential nutrients. National survey data also indicate that excessive consumption of added sugars is contributing to overconsumption of discretionary calories by Americans. On the basis of the 2005 US Dietary Guidelines, intake of added sugars greatly exceeds discretionary calorie allowances, regardless of energy needs. In view of these considerations, the American Heart Association recommends reductions in the intake of added sugars. A prudent upper limit of intake is half of the discretionary calorie allowance, which for most American women is no more than 100 calories per day and for most American men is no more than 150 calories per day from added sugars.

Remuscularizing failing hearts with tissue engineered myocardium

Supporting or even replacing diseased myocardium with in vitro engineered heart muscle may become a viable option for patients with heart failure. The key to success will be to (1) generate human heart muscle equivalents in vitro, (2) integrate the latter into a failing heart, (3) ensure long-term functional competence of the grafts, and (4) prevent unwanted effects including arrhythmias, inflammation/rejection, and tumor formation. Several promising tissue engineering technologies have already been developed and are presently being tested in animal models. The rapidly evolving field of human stem cell biology has in parallel identified unique cell sources of potential clinical relevance. Somatic cell reprogramming and nontransduced, nonembryonic pluripotent stem cells may be of particular interest to eventually provide patient-specific cells and tissues. Yet, limited cardiac differentiation and cell immaturity still restrict a broad application of any stem cell type in cardiac muscle engineering. Bioreactor technologies, transgenic "optimization," and growth factor, as well as physical conditioning, have been used to address these caveats. This review summarizes different tissue engineering modalities, speculates on potential clinical uses, provides an overview on cell sources that may ultimately facilitate a patient-specific application, and discusses limitations of tissue engineering-based myocardial repair.

Preventing obesity: challenges and pitfalls for health promotion

OBJECTIVE

To explore challenges to health promotion strategies against obesity, with special attention to the Scandinavian context.

METHODS

Analytic induction, a procedure for verifying theories and propositions, based on purposefully selected literature references, with subsequent critical reflection.

RESULTS

Health promotion efforts against obesity face challenges related to the unequal distribution of vulnerability to weight gain within the population, and to the complex neuroregulatory determinants that explain why obesity is not just a simple matter of lifestyle. Cultural understandings of identity and morality may create victim blaming and disempowerment, thus obstructing clinical health promotion strategies for weight control. Finally, the conceptual validity of obesity measurements and their predictive power deserves attention.

CONCLUSION

Preventing obesity is difficult. Awareness of individual vulnerability and neurobiological mechanisms that lead to weight gain must be taken into account when strategies for health promotion are developed. These strategies must transcend a simplistic energy balance view.

PRACTICE IMPLICATIONS

Clinical health promotion needs to be highly individualized and tailored. Preventing weight gain requires attention to the person's sociodemographic, cultural and genetic characteristics. Cultural trends such as sedentary lifestyles and the nutrition transition should be counteracted without turning body weight control into a question of morality and inferior identity.

Impact of body fat mass extent on cardiac autonomic alterations in women

BACKGROUND

Obesity has been associated with significant abnormalities of the cardiac autonomic regulation. However, the precise impact of increasing body weight on cardiac autonomic function and the metabolic and hormonal contributors to these changes are presently unclear. The aim of our study was to explore in subjects with increasing values of body mass index (BMI) the alterations of cardiac autonomic function and to establish the potential role of various metabolic and hormonal contributors to these alterations.

MATERIALS AND METHODS

We investigated time and frequency domain heart rate variability (HRV) parameters taken from 24-h Holter recordings, and several anthropometric, metabolic and hormonal parameters (plasma glucose, insulin, triglycerides, free fatty acids, leptin and adiponectin) in 68 normoglycaemic and normotensive women (mean age of 40 +/- 3 years), subdivided according to their BMI into 15 normal body weight (controls), 15 overweight, 18 obese and 20 morbidly obese.

RESULTS

Heart rate was increased and HRV was decreased in the morbidly obese group as compared with controls. In overall population, a negative association linked body fat mass (FM) to HRV indices. None of the metabolic and hormonal parameters were significantly related to the HRV indices, after they were adjusted for the body FM.

CONCLUSIONS

Morbidly obese, normoglycaemic and normotensive young women have increased HR and low HRV, indicating an abnormal cardiac autonomic function and representing a risk factor for adverse cardiovascular events. A decrease of HRV parameters is associated with a progressive increase of body FM. Other metabolic and hormonal factors, characterising obesity, do not show an independent influence on these HRV alterations.

Divergent fifteen-year trends in traditional and cardiometabolic risk factors of cardiovascular diseases in the Seychelles

Objective

Few studies have assessed secular changes in the levels of cardiovascular risk factors (CV-RF) in populations of low or middle income countries. The systematic collection of a broad set of both traditional and metabolic CV-RF in 1989 and 2004 in the population of the Seychelles islands provides a unique opportunity to examine trends at a fairly early stage of the "diabesity" era in a country in the African region.

Methods

Two examination surveys were conducted in independent random samples of the population aged 25–64 years in 1989 and 2004, attended by respectively 1081 and 1255 participants (participation rates >80%). All results are age-standardized to the WHO standard population.

Results

In 2004 vs. 1989, the levels of the main traditional CV-RF have either decreased, e.g. smoking (17% vs. 30%, p < 0.001), mean blood pressure (127.8/84.8 vs. 130.0/83.4 mmHg, p < 0.05), or only moderately increased, e.g. median LDL-cholesterol (3.58 vs. 3.36 mmol/l, p < 0. 01). In contrast, marked detrimental trends were found for obesity (37% vs. 21%, p < 0.001) and several cardiometabolic CVD-RF, e.g. mean HDL-cholesterol (1.36 vs. 1.40 mmol/l, p < 0.05), median triglycerides (0.80 vs. 0.78 mmol/l, p < 0.01), mean blood glucose (5.89 vs. 5.22 mmol/l, p < 0.001), median insulin (11.6 vs. 8.3 μmol/l, p < 0.001), median HOMA-IR (2.9 vs. 1.8, p < 0.001) and diabetes (9.4% vs. 6.2%, p < 0.001). At age 40–64, the prevalence of elevated total cardiovascular risk tended to decrease (e.g. WHO-ISH risk score ≥10; 11% vs. 13%, ns), whereas the prevalence of the metabolic syndrome (which integrates several cardiometabolic CVD-RF) nearly doubled (36% vs. 20%, p < 0.001). Data on physical activity and on intake of alcohol, fruit and vegetables are also provided. Awareness and treatment rates improved substantially for hypertension and diabetes, but control rates improved for the former only. Median levels of the cardiometabolic CVD-RF increased between 1989 and 2004 within all BMI strata, suggesting that the worsening levels of cardiometabolic CVD-RF in the population were not only related to increasing BMI levels in the interval.

Conclusion

The levels of several traditional CVD-RF improved over time, while marked detrimental trends were observed for obesity, diabetes and several cardiometabolic factors. Thus, in this population, the rapid health transition was characterized by substantial changes in the patterns of CVD-RF. More generally, this analysis suggests the importance of surveillance systems to identify risk factor trends and the need for preventive strategies to promote healthy lifestyles and nutrition.

The growing Canadian energy gap: more the can than the couch?

OBJECTIVE

The present study describes the trajectory of the energy gap (energy imbalance) in the Canadian population from 1976 to 2003, its temporal relationship to adult obesity, and estimates the relative contribution of energy availability and expenditure to the energy gap. It also assesses which foods contributed the most to changes in available energy over the study period.

DESIGN

Annual estimates of the energy gap were derived by subtracting population-adjusted per capita daily estimated energy requirements (derived from Dietary Reference Intakes) from per capita daily estimated energy available (obtained from food balance sheets). Food balance sheets were used to assess which foods contributed to changes in energy availability. Adult obesity rates were derived from six national surveys. The relationship to the energy gap was assessed through regression analysis.

RESULTS

Between 1976 and 2003, per capita daily estimated energy availability increased by 18 % (1744 kJ), and increased energy availability was the major driver of the increased energy gap. Salad oils, wheat flour, soft drinks and shortening accounted for the majority of the net increase in energy availability. Adult obesity was significantly correlated with the energy gap over the study period.

CONCLUSIONS

The widening energy gap is being driven primarily by increased energy availability. The food commodities driving the widening energy gap are major ingredients in many energy-dense convenience foods, which are being consumed with increasing frequency in Canada. Policies to address population obesity must have a strong nutritional focus with the objective of decreasing energy consumption at the population level.

Distinctive modulation of inflammatory and metabolic parameters in relation to zinc nutritional status in adult overweight/obese subjects

Overweight and obesity are associated with low grade of inflammation and chronic inflammatory response characterized by abnormal production and activation of some pro-inflammatory signalling pathways. Taking into account that obesity is the direct result of an imbalance between energy intake and energy expenditure, the nutritional factors in the diet, with particular focus on zinc, may play a pivotal role in the development of obesity-associated comorbidities. Considering the potential interactions among zinc nutritional status, inflammation, overweight/obesity and insulin secretion, the aim of the present work was to clarify the influence of zinc dietary intake on some metabolic, inflammatory and zinc status parameters in adult overweight/obese subjects. We found a close interrelationship between nutritional zinc and obesity. In particular, subjects with a lower zinc dietary intake display a deeper inflammatory status, general impairment of the zinc status, an altered lipid profile and increased insulin production with respect to obese subjects with normal zinc dietary intake. Moreover, in the presence of low dietary zinc intake, the obese subjects are less capable to respond to oxidative stress and to inflammation leading to the development of obesity or to a worsening of already preexisting obesity status. In conclusion, a possible zinc supplementation in obese subjects with a deeper inflammatory status and more altered zinc profile may be suggested in order to limit or reduce the inflammation, taking also into account that zinc supplementation normalizes "inflammaging" as well as zinc profile leading to a correct intra- and extracellular zinc homeostasis.

Promoting Physical Activity in Minority Populations

This review discusses evidence-based perspectives on promoting physical activity in minority populations. Future directions for inquiry and empirically driven public policy initiatives also are addressed.

A cross-sectional prevalence study of ethnically targeted and general audience outdoor obesity-related advertising

CONTEXT

Commercial marketing is a critical but understudied element of the sociocultural environment influencing Americans' food and beverage preferences and purchases. This marketing also likely influences the utilization of goods and services related to physical activity and sedentary behavior. A growing literature documents the targeting of racial/ethnic and income groups in commercial advertisements in magazines, on billboards, and on television that may contribute to sociodemographic disparities in obesity and chronic disease risk and protective behaviors. This article examines whether African Americans, Latinos, and people living in low-income neighborhoods are disproportionately exposed to advertisements for high-calorie, low nutrient-dense foods and beverages and for sedentary entertainment and transportation and are relatively underexposed to advertising for nutritious foods and beverages and goods and services promoting physical activities.

METHODS

Outdoor advertising density and content were compared in zip code areas selected to offer contrasts by area income and ethnicity in four cities: Los Angeles, Austin, New York City, and Philadelphia.

FINDINGS

Large variations were observed in the amount, type, and value of advertising in the selected zip code areas. Living in an upper-income neighborhood, regardless of its residents' predominant ethnicity, is generally protective against exposure to most types of obesity-promoting outdoor advertising (food, fast food, sugary beverages, sedentary entertainment, and transportation). The density of advertising varied by zip code area race/ethnicity, with African American zip code areas having the highest advertising densities, Latino zip code areas having slightly lower densities, and white zip code areas having the lowest densities.

CONCLUSIONS

The potential health and economic implications of differential exposure to obesity-related advertising are substantial. Although substantive legal questions remain about the government's ability to regulate advertising, the success of limiting tobacco advertising offers lessons for reducing the marketing contribution to the obesigenicity of urban environments.

Physical Activity and Cardiovascular Disease: How Much is Enough?

Physical inactivity is an established risk factor for cardiovascular diseases. However, while physical activity is recommended as a component of healthy lifestyle, the amount (intensity, duration and frequency) of physical activity required to protect against coronary heart disease (CHD) and cerebrovascular disease (i.e., stroke) is unclear. In general, there is a graded inverse association of physical activity with CHD and total cardiovascular disease (the combination of CHD and stroke). The patterns of association between physical activity dose and stroke are less clear; individual studies suggest a threshold effect for benefits, while meta-analytic studies report a graded inverse association. Despite known differences in physical activity behaviors between men and women, the patterns of association between dose of activity and cardiovascular diseases are similar by gender. Observational studies of walking behaviors and one recent clinical trial suggest that lower "doses" of physical activity are associated with a lower risk of cardiovascular disease. Thus, with very few specific cautions, there is enough evidence to recommend to healthy adults that any activity is beneficial and that more activity is even better.

Measurement of park and recreation environments that support physical activity in low-income communities of color: highlights of challenges and recommendations

The capacity of public parks and recreation environments to promote physical activity for low-income communities of color is receiving increased attention from researchers and policymakers. As a result, several systems to measure park and recreation environments have been recently developed. Developing measures is important because they are critical to establishing key correlates and determinants that drive physical activity and inform intervention strategies. This paper briefly reviews recently developed approaches for measuring physical environments within public parks and recreation areas. It critiques the capacity of these approaches to advance an understanding of how parks and recreation settings contribute to physical activity in low-income communities of color. Residents of low-income communities of color are usually found to have lower physical activity, and this may be due partly to a disparity in access to parks and other recreation environments. Three primary recommendations are presented. First, future measurement tools should explicitly reflect inequality in the built environment in terms of availability and quality of parks and recreation areas. Second, measurement strategies should incorporate research on recreation activity and setting preferences important in low-income communities of color. Finally, the perceptions of residents of low-income communities of color should be reflected in measurement approaches. One strategy for incorporating the perceptions is community-based participatory research. The rapid development of high-quality tools for measuring parks and recreation environments is encouraging. However, existing measures should be tested and refined in varying social-ecologic conditions, and new tools should be developed specifically for nuances associated with low-income minority communities.

Reducing obesity: motivating action while not blaming the victim

CONTEXT

The rise in obesity in the United States may slow or even reverse the long-term trend of increasing life expectancy. Like many risk factors for disease, obesity results from behavior and shows a social gradient. Especially among women, obesity is more common among lower-income individuals, those with less education, and some ethnic/racial minorities.

METHODS

This article examines the underlying assumptions and implications for policy and the interventions of the two predominant models used to explain the causes of obesity and also suggests a synthesis that avoids "blaming the victim" while acknowledging the role of individuals' health behaviors in weight maintenance.

FINDINGS

(1) The medical model focuses primarily on treatment, addressing individuals' personal behaviors as the cause of their obesity. An underlying assumption is that as independent agents, individuals make informed choices. Interventions are providing information and motivating individuals to modify their behaviors. (2) The public health model concentrates more on prevention and sees the roots of obesity in an obesogenic environment awash in influences that lead individuals to engage in health-damaging behaviors. Interventions are modifying environmental forces through social policies. (3) There is a tension between empowering individuals to manage their weight through diet and exercise and blaming them for failure to do so. Patterns of obesity by race/ethnicity and socioeconomic status highlight this tension. (4) Environments differ in their health-promoting resources; for example, poorer communities have fewer supermarkets, more fast-food outlets, and fewer accessible and safe recreational opportunities.

CONCLUSIONS

A social justice perspective facilitates a synthesis of both models. This article proposes the concept of "behavioral justice" to convey the principle that individuals are responsible for engaging in health-promoting behaviors but should be held accountable only when they have adequate resources to do so. This perspective maintains both individuals' control and accountability for behaviors and society's responsibility to provide health-promoting environments.

Gender differences in obesity related cardiovascular risk factors in Spain

BACKGROUND

Obesity and overweight are increasing progressively leading to an increase in cardiovascular risk factors and cardiovascular events.

METHODS

The MESYAS Registry (Metabolic Syndrome in Active Subjects) recruited active workers from their annual health examinations in Spain through 2003. Body mass index was used to diagnose overweight and obesity. Metabolic syndrome (MS) and risk factors were assessed according to the ATP-III definitions.

RESULTS

19,041 subjects were included (80% males), mean age 42.2 (10.7). The prevalence of overweight was 44.6% (44.0-45.2), obesity 17.3% (17.0-17.5) and MS 12.0% (11.8-12.2). Women had lower prevalence of all cardiovascular risk factors. Multivariate analysis showed independent associations between overweight (OR: 2.4; 95% CI 2.2-2.6) or obesity (OR: 5.3; 95% CI 4.7-5.9) and any other two MS criteria. Overweight and obesity were independently associated with all cardiovascular risk factors, except low high-density lipoproteins in women. Significantly higher association was found in women between obesity and diabetes (OR: 13.6; 95% CI 3.8-48.6), MS (OR: 10.6; 7.6-14.8), hypertriglyceridemia (OR: 8.6; 95% CI 5.6-13.1), and impaired fasting glucose (OR: 3.7; 95% CI 2.7-5.3).

CONCLUSIONS

Overweight and obesity are strongly related to classical cardiovascular risk factors, atherogenic dyslipidaemia and MS. Obesity has higher association to insulin-resistance related risk factors in women.

Steps in the design, development and formative evaluation of obesity prevention-related behavior change trials

Obesity prevention interventions through dietary and physical activity change have generally not been effective. Limitations on possible program effectiveness are herein identified at every step in the mediating variable model, a generic conceptual framework for understanding how interventions may promote behavior change. To minimize these problems, and thereby enhance likely intervention effectiveness, four sequential types of formative studies are proposed: targeted behavior validation, targeted mediator validation, intervention procedure validation, and pilot feasibility intervention. Implementing these studies would establish the relationships at each step in the mediating variable model, thereby maximizing the likelihood that an intervention would work and its effects would be detected. Building consensus among researchers, funding agencies, and journal editors on distinct intervention development studies should avoid identified limitations and move the field forward.

Ethnic minorities and weight control research priorities: where are we now and where do we need to be?

Within the overall obesity epidemic, the burden of obesity and related health problems is particularly high among African Americans, Hispanic/Latino Americans, American Indians, and Pacific Islanders--both children and adults. The often asked question of what types of obesity interventions work in these populations reflects uncertainty about how applicable standard interventions are to diverse socio-cultural groups and socio-environmental contexts. A meta-analysis in this issue of Preventive Medicine (Seo and Sa, 2008. A meta-analysis of psycho-behavioral obesity interventions among US multiethnic and minority adults) includes selected multi-ethnic and minority-focused studies that in total had 40% minority participants. Although the authors' conclusions were congruent with current general guidance for weight loss programs, insights about how to intervene with minority populations were limited by the small amount and nature of the available evidence. Ethnic minorities in the aggregate are now a third of the U.S. population. We should be purposeful in identifying research needs and quality standards for conducting and reporting studies with these populations and in motivating related research. Improving the relevance to and quality of evidence on obesity prevention and treatment for a more diverse set of populations will also improve the weight control literature as a whole.

Public health genomics: translating obesity genomics research into population health benefits

We examine how a public health genomics framework can be used to move genomic discoveries into clinical and public health practice for obesity prevention and treatment. There are four phases of translational research: T1: discovery to candidate health application; T2: health application to evidence-based practice guidelines; T3: practice guidelines to health practice; and T4: practice to population health impact. Types of multidisciplinary research and knowledge synthesis needed for each phase, as well as the importance of developing and disseminating evidence-based guidelines, are discussed. Because obesity genomics research is mostly in the discovery phase or in the very early phases of translation (T1), the authors present this framework to illustrate the range of translation activities needed to move genomic discoveries in obesity to actual applications that reduce the burden of obesity at the population level.