Multifactorial Approaches for the Prevention of Obesity


FEATURE STORY

A position statement of the Philippine Association for the Study of Overweight and Obesity (PASOO) on the need for healthy lifestyle practices to achieve and maintain a healthy weight for everyone

By HERCULES P. CALLANTA, MS, MIA FOJAS, MD, ROBERTO MIRASOL, MD,NEMENCIO NICODEMUS JR., MD, SANIROSE ORBETA, MS, RD, MARJORIE RAMOS, MD, MICHAEL ROSARIO, MD, CELESTE TANCHOCO, DRPH, MPH, RND, EDGARDO TOLENTINO JR., MD


Filipinos are getting fat! The 2013 national survey of the Food and Nutrition Research Institute showed that the prevalence of overweight and obesity among adults in the Philippines has increased to 31.1 percent from 16.6 percent twenty years ago. This doubling in the prevalence is also consistent with data around the world and is alarming because of the association of obesity with several diseases, including heart disease, diabetes and hypertension, together with higher death rates. There are several factors contributing to the rise on overweight and obesity locally.

Data from the Philippines National Nutrition and Health surveys from 1978-2003 shows that while the Filipino food intake has not increased in terms of weight, the energy density of diets has been increasing. This may be a contributory factor to the increasing prevalence of overweight and obesity in the country.

It can be very hard for Filipinos to control the amount of food that we eat because we just get every food that is served freely until we feel satisfied. Our intake of fruits and vegetables is often replaced with sugary and fatty foods which makes our eating unbalanced.

Data from Philippine Statistics Authority suggest that the quantity of what people eat is affected by the accessibility and availability of the foods. Hence, if foods are priced lower, and if foods are always available, people are expected to eat more than the appropriate servings of foods. Another possible reason why people tend to overeat is the lack of recognition on what a reasonable portion looks like.

Before the time of the internet, majority of the screen time was devoted to television. But with the rise of the internet and the increasing portability of devices, smartphones and tablets have taken over. According to a report, in our country of 105.7 million, around 67 million are internet users, with the numbers increasing by the millions for the past year. The average daily time spent using the internet reaches 9 hours and 29 minutes with 3 hours and 57 minutes being spent on social media. The average daily television viewing time including streaming and on-demand services reaches 3 hours and 37 minutes.

The proportion of physically inactive Filipino adults > 20 years is shown to be as high as 92.6 percent in transport-related activities and leisure-related activities in 2003. In a more recent survey (2008), more males have become sedentary in their occupational work and transport-related activities. The females had a slight decrease in sedentary occupational work but increased in transport-related and leisure time activities.

Since lifestyle is the key factor in the development of obesity as shown above, the Philippine Association for the Study of Overweight and Obesity came out with this white paper on the prevention of obesity by addressing lifestyle-related issues. These multifactorial approaches are aimed at providing practical strategies for the Filipinos to follow and adopt.

1. Promote breastfeeding for infants from birth to six months

Breastfeeding is the normal way of providing young infants with optimum nutrition they need for healthy growth and development. The World Health Organization recommends (1) exclusive breastfeeding within the infants’ first 6 months of life; and, (2) continued breastfeeding with the addition of appropriate, adequate and safe complementary foods up to two years old. Exclusive breastfeeding means that the infant receives only breast milk with no other liquids or solids (with the exception of oral rehydration solution, drops or syrups of vitamins, minerals or medicines). The American Academy of Pediatrics (AAP) and the Academy of Nutrition and Dietetics (AND) strongly endorse breastfeeding throughout the infant’s first year of life.

A review of 61 studies concluded that breastfeeding protects against obesity in children and adulthood. The proposed mechanisms include more normal growth patterns (lower early weight gain) possibly associated with lower basal insulin levels in the breastfed versus the formula-fed infant and the inherent control of food intake maintained by the breastfed infant.

Breastfeeding on demand is thought to teach infants to regulate their intake appropriately, based on internal cues for hunger and satiety and in response to their individual growth needs. Formulafed infants may have fewer opportunities to develop this important skill since parents or caregivers may want to follow a set feeding schedule or may encourage the infant to consume a certain amount of formula. These feeding behaviors override the infant’s internal cues and may result in overfeeding and lessen the infant’s ability to self- regulate energy intake.

2. Eat breakfast everyday

Breakfast is the most important meal of the day. It gives a huge boost to start the day right. However, a study found that as much as 12 to 34 percent of youth regularly skip breakfast. Evidence show s that breakfast eaters have lower BMI even with adjustment for potential confounding factors. Another study also showed that increased meal frequency (meals per week) was associated with a 45 percent reduction in the risk for obesity in adults whereas skipping breakfast appeared to be associated with a significant increase d risk in developing obesity. Among adolescents, frequency of breakfast (days per week in three categories: -0, 1-6, 7 days) was inversely associated with weight gain and appeared to have a dose- response association. Most researchers noted that those who skipped breakfast ate significantly more calories during the day than constant breakfast eaters. Breakfast eaters also report reduced intake of dietary fat and cholesterol and increased fiber vs those who skip breakfast.

A meta-analysis looking at the association of breakfast consumption with nutritional adequacy showed consistently superior nutritional profiles among regular breakfast eaters compared to their breakfast skipping peers. Breakfast eaters generally consumed more daily calories yet were less likely to be overweight.

3. Limit overall intake of calorie-dense foods

Calorie density or energy density is the amount of calories in a volume of food, and is usually expressed as kcal/g. Low energy density foods generally have high water and fiber content, with little fat. High energy density foods, on the other hand, have high fat content. Fat is the most energy dense nutrient, containing 9 kcal/g, while protein and carbohydrate only contain 4 kcal/g.

Choosing low calorie-dense foods allows one to take in larger volumes of food and feel more satisfied with fewer calories. The fullness and satiety also helps in the adherence to the diet over a longer period of time, thus leading to weight loss. One randomized control trial showed significant improvements in weight, waist circumference, fasting blood sugar, total cholesterol and bad cholesterol (LDL-C) after seven months in individuals who were assigned to a low energy density diet compared to subjects assigned to a usual diet.

The United States Centers for Disease Control and Prevention (CDC) recommends the following steps in creating a diet low in energy:

• Incorporate a large portion of fruits and vegetables into meals.
• Round out meals by adding starchy fruits and vegetables, whole grains, legumes (peas and beans), lean meats, and low-fat dairy food.
• Pay attention to portion sizes of fried foods, including vegetables; non-whole grains; dairy foods that are not reduced in fat; and fatty cuts of meat. Consume these occasionally in small portions.
• Consume infrequently, with particular attention to portion size, foods with little moisture, such as crackers, cookies, and chips as well as high-fat foods like croissants, margarine, and bacon.

4. Eat a variety of nutrient-dense foods rich in fiber from the different food groups

Eating a variety of food from all the different food groups in the proper amount and balance will supply the required nutrients the body needs. However, variety may be positively or negatively associated with body weight status, depending on the food group, Studies show that more variety consumed from energy dense groups such as sweets, snacks, condiments, entrees and carbohydrate-based foods , was associated with increased adiposity, whereas more variety consumed from energy- weak vegetables, fruit and legume foods , was associated with leanness. Ample fiber intake has been associated with reducing energy density of the diet. High-fiber foods may reduce the hunger associated with caloric (energy) restriction while simultaneously delaying gastric emptying and somewhat reducing nutrient utilization.

Reducing energy-dense variety and increasing energy-weak and micronutrients-dense food variety may help to reduce excess body weight and maintain weight loss. In a study of more than 2200 persons in the National Weight Control Registry, a lower variety consumption from all food groups, except fruits, reported maintenance of weight loss for an average of 6.1 years than people who lost weight over 6 months in a behavioral weight loss program. In another study, subjects in an 18-month standard obesity treatment regimen without specific advice on dietary variety were successful at weight loss if they increased their variety of vegetables and low-fat bread and reduced their variety of high-fat, sweets and oils. Furthermore, high dietary intake of calcium is associated with decreased prevalence of overweight and obesity through the depression of the PTH and 1, 25 dihydroxy Vitamin D which leads to inhibition of lipogenesis and increased lipolysis. In addition, with high intake of calcium, there is increased excretion of fecal fat caused by soap formation.

5. Consume fruits and vegetables in every major meal

Available evidence indicates that persons who consume more fruits and vegetables often have lower prevalence of important risk factors for cardiovascular disease (CVD), including hypertension, obesity, and type 2 diabetes mellitus. Many nutrients and phytochemicals in fruits and vegetables, including fiber, potassium, and folate, could be independently or jointly responsible for the apparent reduction in CVD risk. Functional aspects of fruits and vegetables, such as their low dietary glycemic load and energy density may also play a significant role.

Glycemic index tells us how slow or fast the glucose response is from the food that we eat. It also tells us that dietary fiber, complex carbohydrates and starch structure present in food may be responsible for the slow release of glucose and may be a good factor in diet control and weight management.

It is clear that fruit and vegetables should be eaten as part of a balanced diet, as a source of vitamins, fiber, minerals, and phytochemicals. It may be more important to focus on whole foods and dietary patterns rather than individual nutrients to successfully impact on CVD risk reduction.

6. Limit intake of foods and beverages high in added sugar

Sugar sweetened beverages (SSBs) are any liquids that contained energy-containing sweeteners such as sucrose, high fructose-corn syrup or fruit juice concentrates. These include regular sodas, fruit drinks, sports and energy drinks, vitamin water drinks and coffee and tea with added sugars. A beverage that is 100 percent fruit juice and with no added sweeteners is not included.

Several studies showed positive associations between intake of SSBs, particularly carbonated drinks and weight gain and obesity in both children and adults. The possible explanation is the high sugar content and low satiety of these drinks. A meta-analysis showed that higher intake of SSBs is associated with development of type 2 diabetes mellitus and metabolic syndrome, by promoting weight gain and increase glycemic load leading to insulin resistance.

Limiting sugar sweetened beverage consumption can help prevent obesity, diabetes and metabolic syndrome and may eventually lead to reduction in cardiovascular events. Some simple recommendations to help limit the intake of sugar-sweetened beverages includes:

• Avoid stacking of SSBs at home. Studies show that 60- 80% of calories from SSBs and fruit juices were consumed in the home environment.
• Avoid ordering SSBs or “combo meals” in fastfood shops. A great percentage of SSBs consumption especially in adolescents and young adults is through fastfood s.
• Limit the availability of sugar sweetened beverages like sodas and fruits drinks in school cafeterias. By limiting the accessibility of these beverages, school children may prefer better and healthier choices.
• Limit intake of carbonated drinks to <1-2 serving (12 oz) per month. Evidence shows that those who consumed SSBs more than1-2 servings per day have higher risks of weight gain.

7. Control portion sizes of foods you eat

A serving size refers to a specific amount of food or drink that is defined by common measurements, such as, tablespoons, cups, or ounces. Serving Size can be found in nutrition facts or food labels. A portion size, on the other hand, is the amount of food or drink that ends up on one’s plate or glass respectively; as in the actual amount that one chooses to eat or drink. Here are some helpful tips in controlling portion sizes of foods.

When eating at home:

• Use smaller dishes, bowls, and glasses to help you eat and drink less.
• Try not to eat while busy doing other activities such as watching a TV show, driving or walking.
• Focus on what you are eating; chew your food well to fully enjoy the flavor of your food.
• As it may take about 15 min. for your brain to get the message that you are full, try eating slowly.
• Eat meals regularly; skipping meals may cause you to overeat later in the day.
• Serve your meals on individual plates to help avoid second helpings.
• Eat fewer desserts, fatty dressings, sauces, fried or prepackaged foods as they are high in fat and calories, but they usually don’t make you full.
• Put away your leftovers right away so you won’t get drawn to go back for more.
• If you enjoy alcohol, take only 1 small shot as it adds to calorie intake.
• If you are fond of high-calorie snacks, have only 1 serving of the pack; e.g. 1 scoop of ice cream.

When Eating Out:

• If you ordered a large-sized meal or dessert, split it with a friend or take the half portion home.
• Try to avoid going to eat-all-you-can buffets.
• As much as possible, pick steamed, grilled, or roasted dishes instead of fried ones.
• If you happen to order a high-fat or a high-calorie dish, get the smaller size.
• Choose small-sized meals and drinks instead of the largesized ones, if given a choice.
• If you are feeling full, lay down your cutlery and glass, and skip second helpings instead, enjoy the setting of the place and your company.
• Create a shopping checklist so that you will only buy what is needed.
• When shopping for groceries, try not to buy the foods in which you tend to overeat. If you do, pick the snack sizes or the single portions on the go and eat only a serving of the snack.
• Learn to read food labels or nutrition facts.
• Carefully compare the marketplace portions of foods to their recommended serving sizes.

8. Limit eating out at restaurants especially fast-food restaurants

Fast foods are rich in highly processed meats and refined carbohydrate, sodium, total fat, saturated fat and trans fatty acids, cholesterol and poor in essential nutrients and dietary fibers. A study of young adults followed up for thirteen years found that the highest compared to the lowest quartile of fast food consumption was accompanied with higher weight and waist circumference. Findings of a study in adolescents showed a strong association between fast food outlet near school and increased risk of overweight.

Reasons for undesirable effects of fast foods include the following:

o Fast foods generally have extremely high energy density
o High fat content and inappropriate composition of fatty acids of fast foods is a main dietary risk for chronic disease
o Large portion size, high amount of refined carbohydrates and added sugar and high glycemic load are main characteristics of fast foods
o Sodium content is higher than recommended
o Fast foods were found to have high trans fat

9. Promote moderate to vigorous physical activity for at least 60 minutes per day on most days of the week

The body of evidence linking regular physical activity with improved physiological health and functionality is well-established. It is now regarded as not only preventive of non-communicable diseases but also a significant part of the treatment for leading noncommunicable and metabolic diseases, such as obesity, hypertension, diabetes, hypercholesterolemia, hyperlipidemia, certain cancers and the cardiovascular diseases. It is also associated with improved mental health, known to alleviate depression and anxiety, and to delay the onset of dementia.

It is not necessary to do high amounts of activity or vigorousintensity activity to reduce the risk of NCDs and reap the health benefits of a physically active life. Studies show substantially lower risk when people do 150 minutes of at least moderate-intensity aerobic physical activity a week. The Philippine Physical Activity Guidelines advocate 60 minutes of physical activity across 5 age groups on most days of the week, either continuous or broken down in 10 minute segments, distributed throughout the day. The most dramatic difference in risk is seen between those who are inactive (30 minutes a week) and those with low levels of activity (90 minutes or 1 hour and 30 minutes a week). And while it is always ideal to pursue fulfilling the WHO guidelines for physical activity of 150 – 250 minutes weekly of moderate to vigorous physical activity, getting a little is always better than none at all.

Sedentariness has to be reduced along with increased physical activity through exercise. Therefore, continuous, uninterrupted sitting for an hour should be interspersed with 2-minute physical activity breaks (“Winning the hour”), in the form of walks to the bathroom, routing one’s own papers, or doing gentle simple movements directed towards mobilizing the major joints of the body.

10. Allow a maximum of two hours per day of screen time

The lack of physical activity increases a person’s risk of becoming obese and developing abnormal lipid and glucose levels. Activities that promote sedentary behavior contribute to this problem and includes increased screen time.

Aside from increasing a person’s risk for obesity, an increase in screen-based entertainment also increases risk for cardiovascular events and death from all causes. A study noted that higher events occurred in those with greater than 4 hours per day of screening time compared to those reporting less than two hours per day.

A recent meta-analysis showed that reducing screen time led to a significant body mass index reduction of 0.15 kg/m2 because it lessened the unhealthy snacking commonly associated with screen viewing and increased time for physical activity which could explain the BMI reduction. The study also showed that screen time reductions occurred significantly in adults only and not in children probably because adults were more conscious of their health and are more motivated to follow the recommendations as compared to children.

11. Promote healthy lifestyle habits early in life

Adults must help children develop healthy habits early in life that will bring lifelong benefits. Parents can encourage kids to evaluate their food choices and physical activity habits using the following tips:

• Be a good role model. You don’t have to be perfect all the time, but if kids see you trying to eat right and getting physically active, they’ll take notice of your efforts. You’ll send a message that good health is impor¬tant to your family.
• Keep things positive. Kid’s don’t like to hear what they can’t do, tell them what they can do instead. Keep it fun and positive. Everyone likes to be praised for a job well done. Celebrate successes and help children and teens develop a good self-image.
• Get the whole family moving. Plan times for everyone to get moving together. Take walks, ride bikes, go swimming, garden or just play hide-and-seek outside. Everyone will benefit from the exercise and the time together.
• Be realistic. Setting realistic goals and limits are key to adopting any new behavior. Small steps and gradual changes can make a big difference in your health over time, so start small and build up.
• Encourage physical activities that they’ll really enjoy. Every child is unique. Let your child experiment with different activities until they find something that they really love doing. They’ll stick with it longer if they love it.
• Pick truly rewarding rewards. Don’t reward children with tv, video games, candy or snacks for a job well done. Find other ways to celebrate good behavior.
• Make dinnertime a family time. When everyone sits down together to eat, there’s less chance of children eating the wrong foods or snacking too much. Get your kids involved in cooking and planning meals. Everyone develops good eating habits together and the quality time with the family will be an added bonus.
• Make a game of reading food labels. The whole family will learn what’s good for their health and be more conscious of what they eat. It’s a habit that helps change behavior for a lifetime.
• Stay involved. Be an advocate for healthier children. Insist on good food choices at school. Make sure your children’s healthcare providers are monitoring cardiovascular indicators like BMI, blood pressure and cholesterol.

July 2018 Health and Lifestyle

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