Inequalities in education and national income are associated with poorer diet: Pooled analysis of individual participant data across 12 European countries

Background

Malnutrition linked to noncommunicable diseases presents major health problems across Europe. The World Health Organisation encourages countries to conduct national dietary surveys to obtain data to inform public health policies designed to prevent noncommunicable diseases.

Methods

Data on 27334 participants aged 19-64y were harmonised and pooled across national dietary survey datasets from 12 countries across the WHO European Region. Weighted mean nutrient intakes were age-standardised using the Eurostat 2013 European Standard Population. Associations between country-level Gross Domestic Product (GDP) and key nutrients and nutrient densities were investigated using linear regression. The potential mitigating influence of participant-level educational status was explored.

Findings

Higher GDP was positively associated with total sugar intake (5·0% energy for each 10% increase in GDP, 95% CI 0·6, 9·3). Scandinavian countries had the highest vitamin D intakes. Participants with higher educational status had better nutritional intakes, particularly within lower GDP countries. A 10% higher GDP was associated with lower total fat intakes (-0·2% energy, 95% CI -0·3, -0·1) and higher daily total folate intakes (14μg, 95% CI 12, 16) in higher educated individuals.

Interpretation

Lower income countries and lower education groups had poorer diet, particularly for micronutrients. We demonstrate for the first time that higher educational status appeared to have a mitigating effect on poorer diet in lower income countries. It illustrates the feasibility and value of harmonising national dietary survey data to inform European policy regarding access to healthy diets, particularly in disadvantaged groups. It specifically highlights the need for strong policies supporting nutritional intakes, prioritising lower education groups and lower income countries.

Weight loss maintenance in overweight subjects on ad libitum diets with high or low protein content and glycemic index: the DIOGENES trial 12-month results

BACKGROUND

A high dietary protein (P) content and low glycemic index (LGI) have been suggested to be beneficial for weight management, but long-term studies are scarce.

OBJECTIVE

The DIOGENES randomized clinical trial investigated the effect of P and GI on weight loss maintenance in overweight or obese adults in eight centers across Europe. This study reports the 1-year results in two of the centers that extended the intervention to 1 year.

METHOD

After an 8-week low-calorie diet (LCD), 256 adults (body mass index >27 kg m(-)(2)) were randomized to five ad libitum diets for 12 months: high P/LGI (HP/LGI), HP/high GI (HP/HGI), low P/LGI (LP/LGI), LP/HGI and a control diet. During the first 6 months, foods were provided for free through a shop system and during the whole 12-month period, subjects received guidance by a dietician. Primary outcome variable was the change in body weight over the 12-month intervention period.

RESULTS

During the LCD period, subjects lost 11.2 (10.8, 12.0) kg (mean (95% confidence interval (CI))). Average weight regain over the 12-month intervention period was 3.9 (95% CI 3.0-4.8) kg. Subjects on the HP diets regained less weight than subjects on the LP diets. The difference in weight regain after 1 year was 2.0 (0.4, 3.6) kg (P=0.017) (completers analysis, N=139) or 2.8 (1.4, 4.1) kg (P<0.001) (intention-to-treat analysis, N=256). No consistent effect of GI on weight regain was found. There were no clinically relevant differences in changes in cardiometabolic risk factors among diet groups.

CONCLUSION

A higher protein content of an ad libitum diet improves weight loss maintenance in overweight and obese adults over 12 months.

Objectively measured physical activity and obesity prevention in children, adolescents and adults: a systematic review of prospective studies

This study aimed at synthesizing the prospective associations between measured physical activity (PA) and change in adiposity in children, adolescents and adults following from two previous reviews. Search terms were adapted and a systematic literature search was conducted (January 2000-September 2008) and later updated (up to October 2009), considering observational and intervention studies of weight gain that measured both PA and body composition. Sixteen observational studies (six comprising adults) and five trials (one comprising adults) were eligible. For consistency, whenever possible either baseline PA energy expenditure or accelerometer output (counts min(-1) ) and change in per cent body fat were the extracted exposure and outcome measures. Results of observational studies suggest that PA is not strongly prospectively related with adiposity: five studies on children and three on adults reported no association between baseline PA and change in adiposity, one study found a weak positive association and the other studies observed a weak negative association. Negative associations were more frequently observed in studies that analysed the association between change in the exposure and outcome. Intervention studies show generally no effect on either PA or adiposity. In conclusion, despite the well-established health benefits of PA, it may not be a key determinant of excessive gain in adiposity.

Impact of weight change, secular trends and ageing on cardiovascular risk factors: 10-year experiences from the SOS study

OBJECTIVE

Many short-term studies indicate that 5% weight loss in the obese is enough to induce significant improvements of cardiovascular risk factors. However, it is not known what degree of weight loss is required to improve risk factors over a more extended period of time or how ageing and secular trends per se are influencing risk factors during long-term follow-up.

METHODS

Patients examined after 10 years in the intervention study Swedish Obese Subjects were used for the current analysis. Surgically treated subjects (n=959) and conventionally treated obese controls (n=842) were pooled to obtain a study group with a large range of weight changes. The patients were divided in 11 groups based on the amount of weight change. Analysis of covariance was used to determine the necessary weight change over 10 years for a significant alteration of a risk factor. In a linear regression of risk factor change by weight change, the y intercept was interpreted as the effect of 10 years ageing and secular trends on a given risk factor in the absence of weight change.

RESULTS

The necessary weight loss for significant improvement of risk factors ranged from 10 to 44 kg. At zero weight change, 10 years of ageing was associated with significant increases in systolic blood pressure, pulse pressure, high-density lipoprotein cholesterol and glucose, and with significant decreases in diastolic blood pressure, total cholesterol, triglycerides and insulin.

CONCLUSIONS

The necessary weight loss to maintain a favourable effect on risk factors in an obese population is larger than previously indicated by short-term studies. Treatment effects are influenced by non-weight change-dependant shifts in risk factor levels.

Dietary strategy to manipulate ad libitum macronutrient intake, and glycaemic index, across eight European countries in the Diogenes Study

The aim of this study was to describe the development and implementation of a multifaceted, low-fat, weight-loss strategy for a Pan-European randomized controlled dietary intervention study, Diogenes. There were 891 families with at least one overweight/obese parent who underwent screening. Eligible, overweight/obese adults followed an 8-week weight-loss phase with a fixed low-energy diet (800 kcal). On attaining weight loss of > or = 8%, families were randomized to a 6- or 12-month low-fat (25-30%E) diet either based on national dietary guidelines or one of four interventions: low protein (LP)/low glycaemic index (LGI), LP/high GI (HGI), high protein (HP)/LGI and HP/HGI. The impact of each diet in preventing weight (re)gain was tested. A points-based system was used to manipulate dietary protein and carbohydrate. Manipulating carbohydrate composition involved substituting foods with a relatively high or low GI. A questionnaire was designed and completed by study investigators, providing feedback on the dietary intervention methods used to inform future interventions. The points system allowed macronutrient manipulations without compromising dietary flexibility or enforcing energy restrictions. Reported centre/participant differences in the ease of implementing the intervention may reflect dietary diversity and personal preferences for specific weight-management strategies. The points system provides a useful starting point for designing improved experimental paradigms for the manipulation of dietary intake in future trials.

Developing a methodology for assigning glycaemic index values to foods consumed across Europe

There is growing evidence that the glycaemic index (GI) of the diet is important with respect to body weight and metabolic disease risk. However, research is limited by the paucity of GI values for commonly consumed carbohydrate-rich foods in European countries. A new methodology has been developed for consistent assignment of GI values to foods across five European databases used in the Diogenes intervention study. GI values were assigned according to five decreasing levels of confidence (1) Measured values for specific foods; (2) Published values from published sources; (3) Equivalent values where published values for similar foods existed; (4) Estimated values assigned as one of three values representing low/medium/high GI ranges and (5) Nominal values assigned as 70, where no other value could be assigned with sufficient confidence. GI values were assigned to 5105 foods. In food records collected at baseline, the contribution to carbohydrate intake of foods assigned levels 1-2 ranged from 16% to 43% depending on country, and this increased to 53-81% including level 3 foods. The degree of confidence to assigned GI values differed across Europe. This standardized approach of assigning GI values will be made available to other researchers to facilitate further investigation into the effects of dietary GI on health.

Reflections from a systematic review of dietary energy density and weight gain: is the inclusion of drinks valid?

The association between dietary energy density, increased energy intake and weight gain is supported by experimental evidence, but confirmation of an effect in free-living humans is limited. Experimental evidence supports a role of energy density in obesity through changes in food composition, not drinks consumption. The inclusion of drinks in the calculation creates a variable of questionable validity and has a substantive impact on the estimated energy density of the diet. We posit, based on the experimental evidence, that calculating the energy density of diets by excluding drinks and including calories from drinks as a covariate in the analysis is the most valid and reliable method of testing the relationship between energy density and weight gain in free-living humans. We demonstrate, by systematically reviewing existing observational studies of dietary energy density and weight gain in free-living humans, how current variation in the method for calculating energy density hampers the interpretation of these data. Reaching an a priori decision on the appropriate methodology will reduce the error caused by multiple comparisons and facilitate meaningful interpretation of epidemiological evidence to inform the development of effective obesity prevention strategies.

Should snacks be recommended in obesity treatment? a 1-year randomized clinical trial

OBJECTIVE

To study the effect to recommend no snacks vs three snacks per day on 1-year weight loss. The hypothesis was that it is easier to control energy intake and lose weight if snacks in between meals are omitted.

SUBJECTS/METHOD

In total 140 patients (36 men, 104 women), aged 18-60 years and body mass index>30 kg/m(2) were randomized and 93 patients (27 men, 66 women) completed the study. A 1-year randomized intervention trial was conducted with two treatment arms with different eating frequencies; 3 meals/day (3M) or 3 meals and 3 snacks/day (3+3M). The patients received regular and individualized counseling by dieticians. Information on eating patterns, dietary intake, weight and metabolic variables was collected at baseline and after 1 year.

RESULTS

Over 1 year the 3M group reported a decrease in the number of snacks whereas the 3+3M group reported an increase (-1.1 vs +0.4 snacks/day, respectively, P<0.0001). Both groups decreased energy intake and E% (energy percent) fat and increased E% protein and fiber intake but there was no differences between the groups. Both groups lost weight, but there was no significant difference in weight loss after 1 year of treatment (3M vs 3+3M=-4.1+/-6.1 vs -5.9+/-9.4 kg; P=0.31). Changes in metabolic variables did not differ between the groups, except for high-density lipoprotein that increased in the 3M group but not in 3+3M group (P<0.033 for group difference).

CONCLUSION

Recommending snacks or not between meals does not influence 1-year weight loss.

Snacking frequency in relation to energy intake and food choices in obese men and women compared to a reference population

OBJECTIVE

To investigate snacking frequency in relation to energy intake and food choices, taking physical activity into account, in obese vs reference men and women.

DESIGN

Cross-sectional, descriptive study.

SUBJECTS

In total, 4259 obese, middle-aged subjects (1891 men and 2368 women) from the baseline examination of the XENDOS study and 1092 subjects (505 men and 587 women) from the SOS reference study were included.

MEASUREMENTS

A meal pattern questionnaire describing habitual intake occasions (main meals, light meals/breakfast, snacks, drink-only), a dietary questionnaire describing habitual energy and macronutrient intake and a questionnaire assessing physical activity at work and during leisure time were used.

RESULTS

The obese group consumed snacks more frequently compared to the reference group (P<0.001) and women more frequently than men (P<0.001). Energy intake increased with increasing snacking frequency, irrespective of physical activity. Statistically significant differences in trends were found for cakes/cookies, candies/chocolate and desserts for the relation between energy intake and snacking frequency, where energy intake increased more by snacking frequency in obese subjects than in reference subjects.

CONCLUSION

Obese subjects were more frequent snackers than reference subjects and women were more frequent snackers than men. Snacks were positively related to energy intake, irrespective of physical activity. Sweet, fatty food groups were associated with snacking and contributed considerably to energy intake. Snacking needs to be considered in obesity treatment, prevention and general dietary recommendations.

Body composition in the SOS (Swedish Obese Subjects) reference study

OBJECTIVE

The primary objective was to establish population-based, sex- and age-specific reference data with respect to body composition variables. Secondary objectives were to relate body mass index (BMI) to anthropometric measurements reflecting central adiposity and to body fat (BF). Another objective was to examine if secular changes in adipose tissue distribution occurred during the sampling period, 1994-1999.

DESIGN

Sex- and age-specific data on anthropometric measurements and body composition were cross-sectionally collected in the reference study of Swedish Obese Subjects.

SUBJECTS

In total, 1135 randomly selected subjects (524 men and 611 women), aged 37-61 y, BMI 17.6-45.4 kg/m(2).

MEASUREMENTS

Measures of body fatness and fat distribution (by dual energy X-ray absorptiometry and anthropometry) were collected.

RESULTS

At BMI 25 kg/m(2), relative (absolute) BF mass was 24% (19 kg) in men vs 36% (25 kg) in women, waist circumference was 90 vs 85 cm, and sagittal trunk diameter was 21 vs 19 cm. BF and measures of centralized adipose tissue distribution increased with age in both sexes (P<0.01). In women, waist circumference and sagittal diameter increased (P<0.01) over the sampling period while BMI did not.

CONCLUSIONS

Sex- and age-specific reference data on body composition are reported from a randomly selected sample of Swedish men and women. At given BMIs, women had more BF but smaller waist circumference than men. Secular increases in indices of central obesity were found in women but not in men.

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.

Meal patterns and obesity in Swedish women-a simple instrument describing usual meal types, frequency and temporal distribution

OBJECTIVE

To characterize meal patterns in relation to obesity in Swedish women using a simple instrument describing meal frequency, meal types and temporal distribution.

DESIGN

Cross-sectional parallel group design.

SUBJECTS

Eighty-three obese women from the Swedish Obese Subjects (SOS) study were compared with 94 reference women, randomly recruited from the population.

METHOD

A new, simplified and self-instructing questionnaire was used to assess meal patterns. Usual meal pattern was reported as time and meal type for each intake episode during a typical day.

RESULTS

The obese women consumed 6.1 meals/day compared with 5.2 meals/day among the reference women (P<0.0001). All types of meals except 'drink meals' were significantly more frequently consumed in the obese group. The obese women also displayed a different meal pattern across the day, consuming a larger number of meals later in the day. As a result a larger fraction of each obese woman's total meals were consumed in the afternoon and in the evening/night. There was no difference in the number of obese vs reference women consuming breakfast. Snack meals were positively associated with total energy intake in both groups.

CONCLUSIONS

A new simplified method assessing meal pattern revealed that the number of reported intake occasions across a usual day was higher in obese women compared with controls and the timing was shifted to later in the day. These findings should be considered in the treatment of obesity.

Intake of sweet foods and counts of cariogenic microorganisms in obese and normal-weight women

OBJECTIVE

To study the intake of sweet foods in obese and normal-weight women, while also taking menstrual cycle effects on eating behaviour into consideration. An objective test of the intake of sugar-containing foods was introduced by measuring salivary counts of mutans streptococci and lactobacilli.

DESIGN

A cross-sectional comparison of the intake of sweet foods in obese and normal-weight women. The obese women were also studied longitudinally after 10 weeks in a weight reduction programme.

SUBJECTS

Obese (n=72, body mass index (BMI) 42.0+/-5.2 kg/m2) and normal-weight women (n=67, BMI 22.2+/-1.6 kg/m2) participated.

RESULTS

Mutans streptococci in saliva were higher in obese than in normal-weight women (P<0.0001), although the reported habitual daily intake of sweet foods did not differ. Of the menstruating women, 80% of the obese subjects and 62% of the normal-weight ones (P<0.05) reported periods during the menstrual cycle with an 'extra large' intake of sweet foods; these intakes were higher in obese than in normal-weight women (P<0.01). The obese women reduced their intake of sweet foods after 10 weeks of weight reduction, although these changes were not pronounced enough to significantly affect the counts of cariogenic microorganisms.

CONCLUSIONS

In contrast to most previous cross-sectional studies, this study shows that obese women have a higher intake of sweet foods, especially pre-menstrually. This was indicated by higher salivary counts of cariogenic microorganisms.

SPONSORSHIP

Karolinska Institute Research Funds.

Relief of cardiorespiratory symptoms and increased physical activity after surgically induced weight loss: results from the Swedish Obese Subjects study

BACKGROUND

Obese people frequently suffer from shortness of breath and chest discomfort on exertion, and they often have a sedentary lifestyle. In the present study of patients with severe obesity, we investigated the effects of surgically induced weight loss on cardiorespiratory symptoms and leisure-time physical activity.

METHODS

The Swedish Obese Subjects study is an ongoing intervention trial of obesity consisting of 1 surgically treated group and 1 matched control group. Information on smoking habits, hypertension, diabetes, and sleep apnea was obtained from 1210 surgical cases and 1099 controls who were observed for 2 years. Patients were also asked about symptoms of breathlessness and chest pain and their levels of leisure-time physical activity.

RESULTS

The surgically treated group displayed a mean weight loss of 28 kg (23%) compared with the control group in which the average weight remained unchanged (P<.001). The rates of hypertension, diabetes, and apneas during sleep decreased in surgical cases compared with controls (P<.001), while smoking habits remained largely the same. The surgical group also displayed highly significant improvements in dyspnea and chest pain and increases in physical activity compared with the control group (P<.001). The odds ratio for self-reported breathlessness, chest discomfort, or sedentary behavior after 2 years decreased progressively with the degree of weight loss. Furthermore, patients who recovered from apneas during sleep reduced their odds of having dyspnea and chest discomfort at follow-up, independent of changes in weight.

CONCLUSIONS

Surgically induced weight loss in patients with severe obesity is associated with a marked relief in symptoms of dyspnea and chest pain and promotes increased leisure-time physical activity. Sleep-disordered breathing may be involved in the pathophysiology of breathlessness and chest discomfort in obese subjects.

Long-term effects of a primary health care intervention program for women: lower blood pressure and stable weight

BACKGROUND

In Strömstad, with 10,000 inhabitants, a cardiovascular prevention program was launched during 1985-1987 because of high rates of cardiovascular disease. To study long-term effects in women, an 8-year follow-up was conducted.

METHODS

Participants (n = 114) and nonparticipants (n = 269) in the lifestyle intervention program in 1985-1987 (both groups with cardiovascular risk factors) were compared regarding risk factor levels after 8 years. Effects were also compared to another community not exposed to intervention.

RESULTS

After 8 years, intervention participants showed significant reduction of mean systolic blood pressure compared to the control group and had higher intake of dietary fibers and more-positive attitudes to and better knowledge of healthy diets. There was no increase of mean body weight or serum triglyceride levels whatsoever in the intervention group. Compared with another female population not exposed to intervention, body weight and systolic blood pressure changed in a significantly more favorable way.

CONCLUSIONS

Results from the prevention program could be discerned after 8 years. Advantages in risk factor changes could also be found when comparing with another female population. Given the high level of stroke in women within the community, the blood pressure advantage in the intervention group is particularly encouraging.

Does degree of obesity influence the validity of reported energy and protein intake? Results from the SOS Dietary Questionnaire. Swedish Obese Subjects

OBJECTIVE

To test the validity of a dietary questionnaire which was developed with the particular goal of measuring dietary intake in obese subjects.

DESIGN

Reported energy intake was compared with 24 h energy expenditure measured in a chamber for indirect calorimetry (24 EE) and reported nitrogen intake with nitrogen in urine collected during the 24 h in the chamber.

SUBJECTS

Twenty-nine overweight men and women, body mass index (BMI) ranging from 25.5 49.5 kg/m2.

RESULTS

Reported energy intake correlated significantly with 24 EE (r = 0.50, P = 0.006) and reported urinary nitrogen correlated significantly with urinary nitrogen excretion (r=0.56, P=0.0015). Mean reported energy intake+/-s.d. was 10.2+/-3.6 MJ and mean 24 EEi s.d. was 10.3+/-1.9 MJ. Although this difference was small and non significant, it indicates some underreporting if one can assume that these overweight subjects are less physically active in the chamber than in free-living conditions. Reported nitrogen intake also suggested underreporting at the group level. However, when the data were analysed at the individual level it was clear that the underreporting errors did not increase with increasing degree of obesity.

CONCLUSIONS

Previous studies with the SOS dietary questionnaire have demonstrated that it is possible to obtain plausible energy intakes from both obese and nonobese subjects. This present analysis further demonstrates that the questionnaire discriminates overweight subjects with high and low intakes of energy and protein, using unbiased biomarkers to judge validity. These data provide additional support for the usefulness of the SOS dietary questionnaire.

Birth weight, adulthood BMI, and subsequent weight gain in relation to leptin levels in Swedish women

OBJECTIVE

Leptin seems to be involved in the regulation of energy balance, although little is known about the epidemiology of leptin with respect to prediction of weight gain and incidence of obesity-related diseases. The dual aim of this study is to document characteristics of leptin after long-term storage, and to describe its relation to body weight, from birth to old age, in an ongoing prospective study.

RESEARCH METHODS AND PROCEDURES

A population-based sample of Swedish women was first examined at the ages of 38 to 60 and re-examined 24 years later. This study used 1358 frozen serum samples that had been stored 29 years for analysis of leptin concentrations and their relation to body weight history.

RESULTS

Leptin values obtained from stored samples showed the same correlation with relative weight as that seen in a contemporary sample with similar demographic characteristics. Lower self-reported birth weight was associated with higher leptin levels in adulthood (p = 0.01), controlling for age and adult BMI. Prospective analyses revealed that high leptin in 38 to 46-year-olds predicted subsequent long-term weight gain (p = 0.003), although no significant associations were seen in women initially aged 50 or older.

DISCUSSION

It is feasible to use frozen serum for studying leptin in relation to obesity and related developments many years later. High leptin level was a risk factor for subsequent weight gain in 38- and 46-year-old women. Retrospective analyses involving birth weight suggest that leptin resistance in adulthood might have fetal origins.

Body weight and body composition changes after treatment of hyperthyroidism

Body composition changes in nine adults with hyperthyroidism were determined with dual energy x-ray absorptiometry and computed tomography at diagnosis and after 3 and 12 months of euthyroidism achieved by surgery, antithyroid drugs, or treatment with radioiodine. Mean body weight was 67.6 kg at diagnosis and increased 2.7 kg (P=0.06) and 8.7 kg (P < 0.001) after 3 and 12 months of euthyroidism, respectively. Basal metabolic rate decreased from 2087 Cal/24 h at diagnosis to 1601 Cal/24 h at 12 months (P=0.001), whereas reported energy intake dropped from 3244 to 2436 Cal/24 h (P=0.01). According to dual energy x-ray absorptiometry, body fat was unchanged at 3 months, but increased by 5.3 kg (P < 0.0001) at 12 months. Fat-free mass increased 2.7 kg (P=0.003) at 3 months and 3.5 kg (P < 0.0001) at 12 months. Changes in bone mineral content and density did not reach significance. According to computed tomography, skeletal muscle plus skin areas increased by 11% (trunk) and 18% (thigh) at 3 months and by 17% (trunk) and 25% (thigh) at 12 months. There was no increase in sc adipose tissue (AT) at 3 months, but at 12 months this AT depot increased by 15% (thigh) and 33% (trunk). Intraperitoneal AT showed a borderline significant increase by 28% (P=0.08) at 3 months and by 40% (P=0.015) at 12 months. Areas of visceral organs and bone tissue of femur did not change significantly during the study. It is concluded that during early recovery from hyperthyroidism, priority is given to the replenishment of skeletal muscles and ip AT, whereas sc AT is increased at a later stage.

Familial predisposition for obesity may modify the predictive value of serum leptin concentrations for long-term weight change in obese women

Leptin is believed to play a role in regulating food intake and body weight. The aim of this study was to examine the influence of parental history of obesity on the association between baseline serum leptin concentrations and subsequent 4-y weight changes. Changes in food intake were also considered in the analysis. Middle-aged, obese women with no obese parent (n = 25) or at least one obese parent (n = 24) were included in the analysis. At baseline, women with no parental history of obesity and women with a parental history of obesity did not differ in body mass index (in kg/m2: 41.2 and 40.2, respectively) or median leptin concentrations (40.8 and 38.8 microg/L, respectively). Four-year weight changes varied widely in both groups combined (from -30 to 24 kg). Stratified regression analysis, adjusted for age, weight, and height, revealed that high leptin concentrations predicted less weight gain (or more weight loss) in women with no obese parent (beta = -21.2, P = 0.0006) but played no significant role in predicting weight gain in women with at least one obese parent (beta = -3.8, P = 0.41). Adding changes in energy and fat intakes to the model reduced the association between leptin and weight change to nonsignificance in the women with no obese parent, indicating that the effect of leptin could be explained largely by dietary changes. In conclusion, serum leptin concentrations predict long-term weight change in obese women with no history of parental obesity, an association largely mediated by changes in food intake.

Swedish obese subjects (SOS): an obesity intervention study with a nutritional perspective

OBJECTIVES

Swedish Obese Subjects (SOS) is a multidisciplinary project involving aspects of obesity ranging from description of the severely obese state to effects of surgical intervention on long-term mortality and morbidity. Dietary studies, which represent an integral part of SOS research activities, are the focus of this review.

SUBJECTS AND METHODS

Due to the large number of obese subjects included in the SOS data bases ( > 5000), an early priority of the project was to develop a dietary assessment method which: (i) described usual intake patterns; (ii) could be self-administered by subjects and rapidly processed; and (iii) was equally valid in obese and non-obese individuals.

RESULTS

The SOS method has met these requirements and is now being completed by all subjects at baseline and during the intervention, and by a non-obese reference population. A number of dietary features distinguishing obese subjects have emerged, including: elevated intakes of energy and energy-percent fat; low consumption of alcohol, fruits and vegetables; high dietary disinhibition; frequent consumption of light meals and snacks; and night eating. In the surgical intervention group, a relatively high consumption of sweet foods was associated with better weight loss and maintenance.

CONCLUSIONS

The SOS method appears to be less susceptible to obesity-related under-reporting than traditional dietary methods, and if the distribution of foods and nutrients can be assumed to be as unbiased as the energy intakes, this method should make it possible to capture associations between diet and obesity-related diseases in the future.

VLCD plus dietary and behavioural support versus support alone in the treatment of severe obesity. A randomised two-year clinical trial

OBJECTIVES

To determine whether 12 initial weeks on a Very Low Calorie Diet (VLCD) included in a two-year support program is associated with better long term weight loss maintenance than a dietary and behavioural support program alone. Additionally, to identify characteristics associated with successful treatment or attrition, which can be used in selecting individuals likely to respond to VLCD-programs.

DESIGN

Randomised clinical trial.

SETTING

Two Swedish out-patient clinics.

SUBJECTS

113 obese men and women aged 37-58 y, body mass index (BMI) > 32.0 kg/m2, participating in the Swedish Obese Subjects-(SOS) study.

INTERVENTIONS

One group received VLCD for 12 initial weeks plus regular dietary and behavioural support over two years while the other group received two years of the same supportive program only.

MAIN OUTCOME MEASURE

Weight loss after two years treatment.

RESULTS

Both treatment groups maintained highly significant weight losses at two years but the initial VLCD-treatment appeared to have given no significant long term benefit compared to the supportive program. Examination of selected demographic, psychosocial and dietary characteristics showed that the VLCD-approach was more effective than the supportive strategy alone in men and possibly in individuals sharing household with only one person. High initial hunger-score was associated with attrition, irrespective of treatment.

CONCLUSION

A VLCD-program including long term dietary and behavioural support is a successful treatment for some severely obese subjects, especially men. Further research should be directed towards matching treatments to individuals in order to improve the high recidivism rates generally following weight loss attempts.

Dietary intake in relation to restrained eating, disinhibition, and hunger in obese and nonobese Swedish women

The aims of this study were to: describe dietary intakes of obese and nonobese middle-aged women using a validated food frequency questionnaire; to assess dietary restraint, disinhibition, and hunger by the three factor eating questionnaire (TFEQ) in obese and nonobese samples and determine which of the factors are independently associated with obesity; and to examine correlations between selected nutritional variables and the TFEQ factors. Subjects studied included 179 obese Swedish women (BMI > 32) and 147 nonobese population-based controls (BMI < 28). Age-adjusted mean energy intake was significantly higher in obese women (2730 +/- 78 vs. 2025 +/- 85 kcal, p < 0.0001). In absolute and relative terms, fat intake was higher and alcohol intake was lower in the obese subjects. Disinhibition was the strongest TFEQ factor independently differentiating the obese and nonobese states, i.e., after adjustment for restraint and hunger. Within the obese sample, strong associations were seen between energy intake and disinhibition (p = 0.0005) and hunger (p = 0.0004). The association between energy intake and restrained eating was negative and weaker (p = 0.04). No such associations were seen in nonobese women. Thus, using a dietary instrument that is valid and unbiased with respect to obesity, strong psychological correlates, possibly causal, of variability in energy intake were detected in middle-aged women with obesity. Disinhibition is associated with both obesity and high-energy intakes and is therefore an important factor to consider in the treatment of women with obesity.

Are elevated aminotransferases and decreased bilirubin additional characteristics of the metabolic syndrome?

Abnormal liver tests, as well as morphological changes in the liver, are frequent among obese patients. Other frequent disturbances are visceral fat accumulation, insulin resistance, non-insulin-dependent diabetes mellitus (NIDDM), hypertriglyceridemia, and hypertension; these are set of aberrations known as the metabolic syndrome. In order to investigate a possible relationship between the metabolic syndrome and impaired liver status we examined associations between liver tests, metabolic variables (insulin, glucose, and triglycerids), body composition and nutrition in 1,083 men (BMI 28.8-63.8 kg/m2) and 1,367 women (BMI 26.7-68.0 kg/m2) in the ongoing intervention study of Swedish Obese Subjects (SOS). Standard biochemical techniques were used to assess liver status and metabolic variables. Lean body mass (LBM) and masses of visceral and subcutaneous adipose tissue (AT) were estimated by means of computed tomography (CT) calibrated anthropometric equations. In both genders aspartate aminotransferase and alanine aminotransferase were, or tended to be, positively correlated to fasting serum insulin, visceral AT (women), and alcohol intake. In women, the aminotransferases were also correlated with fasting blood glucose. In both genders alkaline phosphatase was, or tended to be, positively associated with visceral AT, insulin (women), and glucose. Bilirubin was negatively correlated to insulin and visceral AT in men and women. Additional multivariate analyses indicated that alcohol had less explanatory power than serum insulin for the examined liver tests, especially among women. These results suggest that pathological liver tests in the obese may represent an expression of the metabolic syndrome.

Weight change in relation to intake of sugar and sweet foods before and after weight reducing gastric surgery

OBJECTIVE

To test the hypothesis that a diet containing many sweet foods is associated with poor weight loss after gastroplasty.

SUBJECTS AND METHODS

375 severely obese subjects followed for 2 y after vertical banded gastroplasty or gastric banding; 34 subjects followed after gastric bypass.

RESULTS

Total energy and all macronutrients were reduced 2 y after surgery. Sweet foods were less reduced than other foods, resulting in a relative increase of sugar intake. At 2 y a high relative intake of sugar and fat was associated with a low energy intake and a large weight reduction in the gastroplasty group. In the highest quartile of mono+disaccharide intake (> 142 g) weight loss was 29.9 kg compared to 25.1 kg in lowest quartile (> 72 g). Absolute and relative sugar intake before surgery did not predict weight outcome. At 6 months, i.e. during a period of active weight reduction, energy intake was significantly related to weight loss.

CONCLUSION

Gastroplasty patients who continue selecting sweet foods appear to maintain lower energy intakes and lose more weight. However the associations are unlikely to be causal but probably indicative of changes in other aspects of the diet, eg exclusion of regular meals. Since large weight losses are most likely to be associated with low quality diets these results highlight the need for supplementation therapy of gastroplasty patients. Finally the lack of association between presurgical sugar intake and subsequent weight loss brings into question the surgical practice of selectively assigning sweet eaters to gastric bypass.

Predictors and effects of long-term dieting on mental well-being and weight loss in obese women

Sixty moderately obese women (mean BMI = 33, mean age = 43), randomized to a lactovegetarian or regular 1300-kcal weight-reducing diet were followed at 3, 8 and 24 months. Weight follow-up was 92%, while 47% complied with the program throughout with no differences between the two diets with respect to compliance rate, weight loss or behavioral test results. Over 24 months compliers lost a mean 3.9 kg compared to a gain of 1.8 kg in the non-compliers. Short-term improvements in mental well-being measured by the Mood Adjective Check List deteriorated after 2 years to lower levels than at entry. Self-assessed motivation to diet was inversely related to mental well-being at two years. Positive long-term changes of functional status (Sickness Impact Profile) were found. Though subjective prediction of success measured after 3 weeks on diet predicted short-term and maximum weight loss, it did not predict ultimate outcome. More difficulties in resisting emotional and social eating cues (high disinhibition score on the Three-Factor Eating Questionnaire) before and during the diet predicted weight gain. The more initial health-related dysfunction (SIP) the greater the weight regain. Psychological characteristics at baseline did not predict compliance or overall weight loss. The magnitude of weight loss after 24 months was related to amount and duration of maximum weight loss.

Validity and reproducibility of a self-administered dietary questionnaire in obese and non-obese subjects

The validity and reproducibility of a self-administered dietary questionnaire has been tested with specific attention to differences between obese and non-obese subjects. To test the validity, the dietary questionnaire was compared with 4-day food records, 24-h energy expenditure (24EE) and nitrogen excretion in 45 obese and 19 non-obese men and women. Energy intake was 2% higher (non-significantly) from questionnaire than from food records in the non-obese, but 35% higher (P < 0.001) in the obese. Comparing energy intake from the questionnaire with estimated 24EE, the questionnaire gave 4% higher values in both the non-obese and obese, differences which were not significant. The reproducibility in the obese sample that completed the questionnaire twice was comparable to that observed in normal populations. These data suggest that it is possible to obtain information on obese subjects' dietary intake that is at least as valid and reproducible as that from normal weight individuals.