Nutritional Care in

UNIT 9 NUTRITIONAL CARE IN Weight Management

WEIGHT MANAGEMENT
Structure
9.1 Introduction

9.2 Weight Imbalance --- Prevalence and Classification

9.3 Guidelines for Calculating Ideal Body Weight

9.4 Obesity
9.4.1 Etiology

9.4.2 Energy Balance

9.4.3 Metabolic Aberrations and Clinical Manifestations

9.4.4 Consequences

9.5 Management of Obesity

9.5.1 Dietary and Lifestyle Modifications

9.5.2 Pharmaceutical Management

9.5.3 Surgical Management

9.5.4 Preventive Aspects

9.6 Underweight
9.6.1 Etiology

9.6.2 Metabolic Aberrations and Clinical Manifestations

9.6.3 Dietary Management

9.7 Let Us Sum Up

9.8 Glossary

9.9 Answers to Check Your Progress Exercises

9.1 INTRODUCTION
Weight management has assumed a lot of significance in the present scenario with
increasing affluence, abundance of convenience foods and lack of physical activity.
There is nothing mysterious about what causes people to be overweight. Excess
weight is the result of long term, consistent consumption of much more calories than
you are able to expend, irrespective of the etiology. The emphasis in treating obesity
currently has shifted from mere ‘weight loss’ to ‘weight management’ which implies
that efforts should be directed towards attaining the best possible weight (desirable
body weight) in relation to overall health.
We have already learnt in the previous unit that obesity is one of the important
factors in the causation of certain types of cancers and many other diseases like
arthritis and cardiovascular disease. In this unit you will come across the significance
of maintaining appropriate weight for preventing certain other types of chronic
degenerative diseases. We will also learn about the various approaches the
overweight, the obese and the morbidly obese individuals need to consider for attaining
desirable weight and more importantly, how you can prevent putting on weight in
the first place. 189
Clinical Therapeutic Too much deviation on either side from the appropriate range of body weight increases
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our risk of health problems. Just as overweight as the result of positive energy balance,
underweight results when the energy balance is negative. Obsession with slimming,
especially in the adolescent age group may result in eating disorders like anorexia
nervosa and bulimia nervosa. How to cope with problems of underweight? This is
the focus of the second part of the unit.

Objectives

After studying this unit, you will be able to:

 explain the importance of maintaining a desirable weight throughout the life,

 enumerate the guidelines for calculating the ideal body weight, and

 describe the causative factors, prevention and treatment of various conditions

related to weight management (such as obesity, underweight).

9.2 WEIGHT IMBALANCE --- PREVALENCE AND

CLASSIFICATION
You are aware that obesity is one of the major public health problems of the world.
Earlier a problem of the developed nations, it is now increasingly afflicting our country.
Maintenance of a fairly constant body weight is of vital importance in increasing the
life expectancy, as well as, quality of life of individuals and communities. It is a fact
that exaggerated weight fluctuations on either side (underweight or overweight) of a
desirable range of weight lead to an increase in the morbidity/mortality rate.

Prevalence

WHO (2018) estimates that about 462 million adults are underweight. At the same
time, there are over 1.9 billion adults worldwide who are moderately or severely
overweight. WHO states that world wide obesity has nearly tripled since 1975 and
that the growth in the number of severely overweight adults is expected to double
that of underweight adults during 1995-2025.

Now, let us have a look at the situation in developed countries. As per the report of
National Health and Nutrition Examination Surveys (NHANES) conducted by the
Centers for Disease Control and Prevention, 2015-16, currently 71.6% of U.S. adults
age 20 years and older are overweight and 39.8% are obese. These figures stood at
70.7% and 37.9%, respectively during 2013-2014 implying thereby that there has
been a consistent increase in prevalence of obesity.

The increase in prevalence of obesity among children also is a cause of great concern.
Estimating true prevalence is difficult because of the lack of agreement of different
bodies in defining obesity in children and adolescents. However, data from 79 developing
countries and a number of industrialized countries suggests that, by WHO standards,
about 41 million children under 5 years old are overweight or obese which 52 million
children are wasted, 17 million are severely wasted & 155 million are stunted Worldwide
(WHO, 2018)

Obesity in India

The results of a recently concluded study on the prevalence of obesity in urban Delhi
by the National Family Health Survey-4 (2015-16) has projected that 24.6% of the

190
males and 33.5% of females belonging to the both urban and rural area are currently Nutritional Care in
Weight Management
overweight with even higher prevalence of abdominal obesity. In India, these figures
are 20.6% for women and 18.9% for men. If present trends continue, the situation can
get worse even within a decade and overweight can emerge as the single most important
public health problem in adults. This is despite the fact that one fourth of our country’s
population still falls below the poverty line. So we have learnt that :

* 462 million adults are underweight while 1.9 billion are overweight.

* During the past 10 years there is 2.4% rise in overweight and 3.9% rise in
obese Americans while there is 2.6% rise in percentage of obese children
(5-14 years).
* Roughly 140% of Indians belonging to the both urban and rural areas are
over weight. With increasing numbers every years, obesity could become a
public health problem in adults.

Classification

Obesity is defined as a condition with accumulation of excess body fat. Do you think
that a measure of how much fat a person has in its body would serve as a tool for
classification of obesity? No, because the measurement of direct body fat is difficult,
so we use an indirect method, a ratio called the Body Mass Index (BMI) also termed
Quetelet’s index. This ratio estiminates dependence on frame size and provides the
most useful method of measuring obesity in populations. BMI can be calculated from
the following equation:

Weight (kg)
BMI =
Height (m) 2

where kg = kilogram, m = metre

By this method, various grades of obesity, normal and underweight can be known. Our
BMI value near 18.5 to 24.9 is the ideal value for us to remain healthy and enjoy a
quality life. Table 9.1 presents the weight status according to the BMI range.

Table 4.2: Weight status according to BMI

Classification BMI (kg/m2)

International Asian
Underweight <18.5 < 18.5
Normal 18.5-24.9 18.5-22.9
Overweight 25.0 - 29.9 23.0-24.9
Obese >30 >25
Obese (Grade I) 30-34.9
Obese (Grade II) 35.0-39.9
Obese (Grade III) > 40
*Source : WHO (2004)

So have you calculated the ratio for yourself? You can keep it a secret if you so
desire.
Interestingly it has been found that for a given BMI, Indians have more body fat
than other ethnic groups, both within and outside Asia. This relative increase in 191
Clinical Therapeutic adiposity in Indians has led to the suggestion that the BMI cut-off for non-
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communicable diseases such as obesity should be reduced for Indians to about 23
kg/m2 or lower. In other words refer to it as a public health action point at a BMI
of 23 kg/m2.

So then adiposity can be inferred from the BMI, however, this may not be sufficient
to fully explore relationship between body fat and alterations in human health.
Besides, the BMI, the location of the fat in the body is also important. In this
context the measurement of waist and hip circumference and their ratio is crucial.
The waist to hip ratio is described next.

Waist to Hip Ratio (WHR)

Two individuals who have the same BMI and the same total body fat may have
different abdominal fat mass. Abdominal fat accumulation increases the risk of a
number of chronic degenerative diseases.

The waist-hip ratio (waist circumference divided by hip circumference) therefore

is a simple method for distinguishing between fatness in the lower trunk
(hip and buttocks) and fatness in the upper trunk (waist and abdomen area). A
WHR of >1.0 for men and >0.85 for women is an indicator of abdominal obesity.
Lower trunk fatness (i.e. lower waist to hip ratio) is often referred to as
‘gynoid obesity’. Upper trunk or central fatness (higher waist to hip ratio) is called
‘android obesity’.

How do you make these measurements? Waist and hip measurements are taken on
standing posture and the unit used is centimeter. Waist is measured around the
navel and hip is measured around its broadest part. You may have realize that in
addition to having a normal BMI value, it is also important for us to have a normal
WHR to have a healthy, as well as, attractive body.

Next, let us learn about the classfication of obesity and underweight in children.

Obesity in Children
It is difficult to measure overweight or obesity in children and adolescents because
they grow and mature at different rates. Weight status in children can be classified
based on percentile curves for BMI for age as per the WHO Technical Report
(1995). Table 9.2 presents the weight status based on percentile curves of BMI
for age.

Table 9.2: Weight status based on percentile BMI for age

Weight Status BMI for age

Underweight < 5th percentile

At risk of overweight > 85th to <95th percentile

Overweight > 95th percentile

Overweight or at risk > 85th percentile

The latest BMI for age percentiles for boys and girls 2 to 20 years have been
published by the United States National Center for Health Statistics (NCHS) in
collaboration with the National Center for Chronic Diseases Prevention and
Health Promotion in the year 2000 which may be applied to affluent Indian
children also.

192 Now that we are clear about how to classify obesity and underweight, we will
further look at the guidelines for calculating the ideal body weight.
 Nutritional Care in
9.3 GUIDELINES FOR CALCULATING IDEAL Weight Management

BODY WEIGHT (IBW)

What is the ideal body weight for me? Am I obese? Am I underweight? These are the
questions that must have come to your mind as you stepped into your teens. The three
main factors that determine your ideal weight are your age, sex and height. You have
already learnt in the previous section about two important indices of body weight that
help in the evaluation of your current weight status, i.e., calculation of BMI and the
measurement of WHR. In addition, you have standard height and weight charts for
adult males and females that help you to determine the range of weight which is
appropriate or desirable for you at a given height.
You must appreciate that the best weight for a given individual’s height, age, bone
structure and muscular development is not known exactly. A lot of people continue to
gain weight till the fourth or fifth decade of their life which is neither inevitable nor
physiologically necessary. In general, the best weight is the weight at which you both
look and feel your best. The life insurance statistics, on which the height weight standards
are normally based, tell us that the most nearly ideal weight to maintain throughout life
is that which is proper at the age 25 for your height and body build. Age, of course, is
an important factor in determination of body weight in the growing stage, i.e., for
children. Table 9.3 and 9.4 below give the standard height and weight charts for
Indian adult males and females and also for children at different ages. You can also
use these charts to assess whether for your height the weight is ideal or not.
Table 9.3: Standard height and weight For indian men and women
Men Women
Height
Weight (kg.) Weight (1b.) Weight (kg.) Weight (1b.)

1.52 M (5’ 0 ’’ )   50-54 112-120

1.54 M (5’1’’ )   51-55 114-122

1.57 M (5’2’’ ) 56-60 124-133 53-56 117-125

1.59 M (5’3’’ ) 57-61 127-136 54-58 120-128

1.62 M (5’4’’ ) 59-63 130-140 56-60 124-132

1.65 M (5’5’’ ) 61-65 134-144 58-61 127-135

1.67 M (5’6’’ ) 62-67 137-147 59-64 130-140

1.70 M (5’7’’ ) 64-68 141-151 61-65 134-144

1.72 M (5’8’’ ) 66-71 145-156 62-67 137-147

1.75 M (5’9’’ ) 68-73 149-160 64-69 141-151

1.77 M (5’10’’ ) 69-74 153-164 66-70 145-155

1.80 M (5’11’’ ) 71-76 157-168 67-72 148-158

1.82 M (6’0’’ ) 73-78 161-173 69-74 151-163

1.85 M (6’1’’ ) 75-81 166-178  

1.87 M (6’2’’ ) 77-84 171-184  

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Source : Life Insurance Corporation of India
Clinical Therapeutic Table 9.4: Height and weight of Indian children
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Height Weight
Age
Male (cm) Female (cm) Male (kg) Female (kg)
3 months 56.8 56.0 5.2 5.1
6 months 62.8 61.7 7.0 6.6
9 months 68.9 66.8 8.0 7.7
12 months 72.8 70.7 8.6 8.3
1-2 years 82.61 79.89 10.94 10.21
2-3 years 91.14 89.63 12.79 12.11
3-4 years 98.36 96.21 14.78 13.79
4-5 years 104.70 104.19 16.12 15.85
6 years 118.9 117.3 22.1 21.4
7 years 123.3 122.7 24.5 24.3
8 years 127.9 126.8 26.4 26.1
9 years 133.6 132.3 30.0 29.7
10 years 138.5 138.5 32.4 33.5
11 years 143.4 144.1 35.3 36.5
12 years 148.9 150.3 38.8 42.6
13 years 154.9 153.0 42.9 44.4
14 years 161.7 155.1 48.3 46.7
15 years 165.3 155.3 52.2 48.2
16 years 168.4 155.4 55.4 49.8
17 years 168.9 156.4 59.0 49.9
18 years 169.4 157.2 62.0 50.0
Compiled from ‘A Textbook of Foods, Nutrition and Dietetics’ (2 nd Rev. Ed.), Raheena Begum, 1997.

Check Your Progress Exercise 1

1. Fill in the blanks:
a) WHO 2018, estimates that ........................... million adults are overweight
while ........................ million adults are underweight.
b) About 41 million children in the age group of ........................ years are
overweight worldwide.
c) Currently ........................ million children are wasted and .....................
and ........................ million children are stunted worldwide.
d) A WHR of greater than ............................ for men and greater than
........................ for women is an indicator of abdominal obesity.
2. What method is used for classifying a person overweight? How is it calculated?
.................................................................................................................
.................................................................................................................
.................................................................................................................
3. What are the factors that determine one’s ideal body weight?
.................................................................................................................
.................................................................................................................

194
.................................................................................................................
 Nutritional Care in
4. Match the items in Column A with the items in Column B. Weight Management

Column A Column B
i) WHR a) <18.5
ii) Underweight b) >0.85 for women
iii) Ideal BMI c) >95th percentile
iv) Overweight d) 18.5-24.9
v) Obesity (grade I) e) 30 to 34.9

Having learnt about the IBW and how the weight status can be classified, we shall
now consider the problem of obesity and underweight in a detailed manner. Let us
take up obesity first.

9.4 OBESITY
Obesity is a condition resulting from accumulation of excess body fat. The fat
deposition takes place because over a period of time, people consume diets which
provided much more energy than they were able to expend for their metabolism,
physical activity and growth. The prevalence of obesity in developing countries has
increased. This is because communities have emerged from a life style of subsistence
towards a life style of affluence. In India, there has been an increased migration of
the rural population to urban areas. This shift also has been a contributing factor to
life style changes including significant reduction in physical activity leading to changes
in weight.
Let us look at the factors that contribute to obesity.

9.4.1 Etiology
What are the causes of obesity? However simple the question may sound, the answer
to it is not all that simple. We cannot deny that excess weight results from positive
energy balance or consistent consumption of excess calories than the body is able to
expend. This means that obesity can be corrected by balancing the intake and output
of calories consumed and expended. Thus, it is not an easy task to accomplish because
obesity is the net result of a complex interplay of genetic predisposition towards fat
storage and a number of environmental factors that determine the weight status of an
individual.
We cannot change our heredity but we can, to a certain extent, exercise control over
environmental factors by carrying out suitable modifications in our life style. Indians
as an ethnic group are at a disadvantage. It is a fact that for a given degree of obesity
or BMI, Indians have higher body fat percent and visceral fat (fat around internal
organs) than other populations which increases the risk of chronic degenerative diseases
in later life. Let’s enumerate the various etiological factors for obesity. We will learn
about each of them in detail also.
 Genetic susceptibility
 Dietary habits
 Physical activity
 Affluence and abundant availability of food
 Psychological factors
 Hormonal imbalance
 Birth weight and childhood growth pattern 195
Clinical Therapeutic Genetic Susceptibility : Some people inherit a tendency to become fat. Earlier, it
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was thought that genetic inheritance ranged from 66% to 80% but now it is believed
that our chances of inheriting our parent’s BMI is about 33%. Obesity or thinness of
an individual is inherited, basically from the biological mother. If our biological mother
has been overweight as an adult, the likelihood of our being heavy is about 75%.
A number of genes are implicated in pathogenesis of obesity: The two genes which
recently have received much attention are the ob gene and the 3 - adrenoreceptor
gene. The ob gene produces leptin (a hormone) which is normally secreted from fat
cells. Mutations in the ob gene cause obesity. Treatment of obese mice with leptin
has shown to reduce food intake and body fat. Some scientists are of the opinion that
the ob gene may not have a major role to play in human obesity.
The 3 - adrenoreceptor gene is basically located in adipose tissue. It regulates
Resting Metabolic Rate and oxidation of fat in human beings. A mutation in this gene
may lead to weight gain. In some individuals, it may increase the body’s ability to
store fat when food is limited and cause an increased risk of obesity when plenty of
food is available and energy expenditure is reduced. However, this does not mean
that it is inevitable for a person to be obese because of genetic mutations. Expression
of the genetic tendency may be controlled by appropriate life style modifications also.
Dietary habits : You are aware that a positive energy balance is one of the major
contributory factors for obesity. Some people are in the habit of eating too much food.
They may also be ignorant about the caloric values of common foods like butter,
cheese, jam or rich baked snacks and desserts, the extra helpings consumed rapidly
increase the amount of calories ingested. Sometimes maintaining social relationships
also contributes to intake of excess calories. As you advance in age, your metabolic
rate slows down and you require less energy to carry out the same set of activities
than that needed 20 years ago. On the same diet and eating habits you will definitely
put on weight. It is believed that women are more likely to be obese in the age group
40-60 years across all geographical regions.
Besides the diet per se, there are certain eating habits which may lead people to
obesity, e.g., those who eat food at a very fast rate tend to chew food less and land up
eating more food. Similarly, nibbling between meals may contribute significantly extra
calories to the total intake than is normally realized. Also, those who tend to eat
whenever food of their liking is available or those who just follow meal times even if
they are not hungry tend to put on weight. Mothers generally eat leftovers of children
because they want to avoid wastage of food, adding on more calories to their own
calorie intake.
Physical activity : Sedentary life style with lack of an exercise schedule tends to
make one obese. As we approach middle age, our physical activity generally decreases
without a corresponding decrease in food consumption leading to obesity. Activity
may be decreased because of a debilitating illness like arthritis or cardiac disease. A
change of occupation or simply because of the fact that period of quiet, rest and
relaxation have increased, may lead to decreased activity. In addition, when we are
more active, the body prefers to metabolize fat as an energy source leading to a
decrease in the adipose tissue.
Affluence and abundant availability of food : With increasing affluence, increase
in purchasing power and abundance of food, people tend to eat more. Intake is more
when people are offered a variety of foods than when a single food is available.
Eating out has become fashionable leading to an increased consumption of junk food
which is rich in calories and short on essential nutrients. The ready availability of and
preference for high fat and/or fast foods also contributes to obesity.
Psychological factors: Lonely, bored and depressed individuals may find solace in
eating. When there is nothing else to do, eating provides diversion resulting in increased
consumption of calories.
196
Hormonal imbalance: Certain diseases associated with secretion of hormones, e.g., Nutritional Care in
Weight Management
hypothyroidism, hypogonadism and Cushing’s syndrome exhibit obesity as one of the
characteristic features. A large number of persons who are unsuccessful in reducing
their weight tend to site hormonal imbalance as causative factor for their obesity but
the fact is that only a very small percentage actually suffers from it. Diagnostic tests
are available which help in finding out if a person is actually suffering from hormonal
imbalance.
Birth weight and childhood growth pattern: It has been shown that slow growth of
the foetus in utero and during infancy is followed by accelerated weight gain in
childhood. This combination of small size at birth and accelerated childhood weight
gain has been found to be associated with exaggeration of adiposity, as well as, insulin
resistance in later life. So can we say that small size at birth and accelerated childhood
weight gain is a predictor of later obesity? Yes, we can.
Having looked at the etiological factors, next let us understand the concept of energy
balance.

9.4.2 Energy Balance

Obesity is a state of positive energy balance created by consumption of calories in
amount excessive to the total energy expenditure (TEE) by the body. TEE comprises
the following:
a) Resting Energy Expenditure (REE)  60-75% of TEE
b) Thermic Energy of Food (TEF)  10% of TEE
c) Energy Expended on Physical Activity (EEPA)  15-30% of TEE
REE is the energy required to sustain normal body functions like circulation, respiration,
pumping of ions across membranes, synthesis of various compounds, maintenance of
body temperature etc. The extent of this expenditure depends upon body size and
composition.
TEF is the energy expended to digest, absorb and metabolize food including synthesis
and storage of various nutrients.
EEPA is the most variable component of total energy expenditure and includes energy
expended in voluntary exercises like in walking, cycling, swimming etc. as also that
expended involuntarily e.g., in shivering and fidgeting. The sum total of REE, TEF
and EEPA gives us the value for total energy expenditure(TEE).
Total Energy = Resting Energy + Thermic Energy + Energy Expended in
Expenditure Expenditure of Food Physical Activity
(TEE) = (REE) + (TEF) + (EEPA)
You are aware that the total energy derived from the food that we consume can be
calculated from the energy provided by protein, fat and carbohydrates present in the
food. Energy provided by 1gram of protein = 4 Kcals, 1 gram of fat = 9 Kcals and
1grams of carbohydrate = 4 Kcals.
Weight status is maintained when the total energy derived from food intake equals
the total energy expended by the body. We tend to lose weight when less energy is
derived from food than is expended. Let us see what happens when an individual is
consuming daily, say, 100 Kcal over and above the amount he is able to expend.
Extra calories ingested/day = 100 Kcal
Extra calories ingested/month = 3000 Kcal
Now 1kg adipose tissue represents = 7700 Kcal (1 gm adipose tissue = 7.7 Kcal)
Weight gain/month = 3000 7700 = 0.38 kg approximately
Weight gain/year = 4.56 kg 197
Clinical Therapeutic You will appreciate that if this continues for a period of, say, five years, theoretically,
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even before the person realizes, he is transformed into a grossly obese individual. It is
hard to believe that as little as one extra chapatti or two teaspoons of butter everyday
will result in about 20 kg weight gain over a period of five years. Even though in
effect, weight is not deposited in as direct proportion as this. Let us see why. With the
increase in energy intake, energy output is affected in a number of ways. Firstly, as
the quantity of food ingested is increased, thermogenic effect of food would also
increase amounting to about 10% of the excess intake. Secondly, the energy stored
would increase both the fat and the fat- free mass resulting in an increase in metabolic
rate. This adaptation of metabolic rate which tends to oppose fluctuation in weight
does not permit weight gain in direct proportion to increase in caloric intake.
The thermodynamics of weight loss is a bit less complicated. As opposed to the great
metabolic cost involved in storage of excess dietary calories as fat, protein or glycogen,
hardly any metabolic cost is involved in mobilization of these stores.
Plateau effect : You must have noticed that when people start following weight reducing
diets, they lose weight rapidly in the beginning, then a little slowly and finally a plateau
is reached when they no longer lose weight. Initially, glycogen stores (sugar stored in
liver) are mobilized which is accompanied by a corresponding loss of water. Then, as
weight is lost, it results in loss of extra muscle which was developed to support the
extra adipose tissue. Loss of lean body mass reduces the RMR rapidly so that on a
given diet, the energy deficit is reduced and the rate of weight loss slows down.
Weight loss stops at this point unless a change is made either in nutritional intake or
physical activity. This fact has been hypothesized as ‘‘set-point theory’’.
Weight cycling: There are a number of obese people who keep loosing and gaining
weight a number of times in their lives. This is called the Yo-yo effect. Every time
they regain lost weight, it takes longer to lose the same amount of weight and also less
time to regain it. This frequent losing and gaining of weight is associated with health
risks related to normal functioning of the heart. Psychologically also repeated weight
gain is quite demoralizing for the obese individual. Withstanding, any amount of
intentional weight loss results in significant reduction in all cause, cardiovascular and
cancer mortality.
Adipose tissue: At this point, it will not be irrelevant to consider how exactly does an
increase in the fat depot take place. For understanding obesity better, it is important
for you to know that fat is stored as triglyceride in fat depots made up of adipose
tissue. A normal adult woman has about 20% to 25% of her body weight as fat while
in men appropriate body fatness is 12% to 15% of body weight. When we put on
weight, there is an increase in the adipose tissue. This may either be a result of
hypertrophy or hyperplasia of adipocytes (fat cells) or a combination of the two
processes. Hypertrophy means increase in the size of adipocytes already present in
the body while an increase in their number is known as hyperplasia. As an adult we
put on weight mostly by hypertrophy of fat cells although in some forms of obesity
hyperplasia may also be there. Hyperplasia basically occurs during infancy and
adolescence as a part of growth process. Fat cell size decreases when we lose weight
for any reason but weight loss does not involve a decrease in the number of adipocytes.
Brown fat and white adipose tissue (WAT): There are two kinds of adipose tissue.
Brown Fat is located around the shoulder blades and kidneys, constituting 1-2% of
body weight. It is highly vascular which is the reason for its brown colour. It is capable
of producing a large amount of heat for cold adaptation by burning of excess energy.
It is a site for conversion of thyroid hormone, thyroxin, to its biologically active form.
White adipose tissue acts as a cushion to protect abdominal organs and is the fat that
accumulates under the skin. Earlier, it was thought that WAT is passive and acts only
as a fat storage depot. WAT, in fact, is a smart tissue and has a number of functions to
perform. It has now been realized that WAT is an endocrine organ, which besides
some other factors, secretes a hormone leptin. Leptin seems to have a role to play in
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reducing appetite or increasing satiety and also in regulation of the energy balance. A Nutritional Care in
Weight Management
deficiency of leptin, therefore, is conducive to obesity. Adipocytes in WAT also have
a number of hormone receptors on their cell surfaces. That is why individuals with
abdominal obesity are prone to developing insulin resistance which initially causes
impaired glucose tolerance and ultimately may cause Diabetes mellitus.

Let us learn about the metabolic aberrations and clinical manifestations of obesity
next.

9.4.3 Metabolic Aberrations and Clinical Manifestations

The state of obesity brings about certain alterations in the normal body processes
which are enumerated herewith and highlighted in Figure 9.1.
Deranged lipid profile: Lipids, as you are already aware, are important dietary
constituents that include fats, steroids, phospholipids and glycolipids. A number of
vitamins and essential fatty acids are associated with them. In obese individuals, the
lipid profile is usually deranged. The triglyceride values are generally high and HDL
cholesterol is low. Both triglycerides and HDL cholesterol are synthesized from
products of digestion of dietary fats. With weight reduction, both these levels come
back to normal.
Insulin resistance: Insulin resistance is a condition in which your body cells cannot
utilize insulin efficiently although sufficient amounts are secreted by the pancreas.
Obesity is a contributing factor towards insulin resistance. Because sufficient insulin
is being produced but the body cells are not able to use it, the blood insulin levels
become high (hyperinsulinaemia). This affects the utilization of glucose leading to
high fasting blood sugar levels and abnormal glucose tolerance. In addition, levels of
plasma glucagon (a hormone produced by pancreas having an effect opposite to that
of insulin), free fatty acids and uric acid also are found to be elevated in obese
individuals. All these altered biochemical parameters get back to normal as weight
loss is affected.
Abnormal Glucose Tolerance
Hyperinsulinaemia
OBESITY Increased Glucagon Level
Hypertriglyceridaemia
Hypercholesterolaemia

Increased Free Fatty Acids

Hyperuricaemia
Figure 9.1: Altered biochemical parameters in obesity

The clinical manifestations are highlighted next.

Clinical manifestations: You must have observed that your overweight friends and
colleagues seem to have less energy which makes them an easy prey for fatigue.
They are also less agile and more likely to fall because of imbalance. They have a
tendency to have high blood pressure and dyspnoea (breathlessness on exertion).
Many of them may have increased susceptibility to developing skin disorders such as
heat rash, intertrigo (superficial inflammation of two skin surfaces that are in contact
with each other such as between thighs), candidiasis (a fungal infection) and acanthosis
nigricans (dark, warty growths in skin folds like groin, armpits and mouth).
What are the consequences of obesity? Let us read and find out.
9.4 .4 Consequences
Obesity has a number of adverse effects and is a risk factor for several problems as
highlighted in Figure 9.2. It is a risk factor for all causes of mortality and morbidity . 199
Clinical Therapeutic
Nutritio n
CONSEQUENCES OF OBESITY

INCREASE IN SLEEP PSYCHOLOGICAL

INFERTILITY
DEGENERATIVE DISORDERS PROBLEMS
DISEASES :

 Risk of morbidity or mortality

 Cardiovascular
 Diabetes Mellitus
 Cancer
 Syndrome X
 Gall Bladder
 Arthritis and Gout

Figure 9.2: Consequences of obesity

Let us know more about the consequences of obesity and deal with each aspect
briefly.
General mortality and morbidity risk: Obesity increases the risk of morbidity and
mortality. The obese are more prone to developing morbidities or other chronic diseases
like, cardiovascular disease including hypertension and dyslipidaemia, non-insulin
dependent diabetes mellitus, gall bladder disease and gout. The risk of developing
some non-fatal conditions like arthritis, back pain, infertility, sleep disorders and other
respiratory conditions leads to increased morbidity among the obese. Let’s discuss
these conditions in slightly more detail.
Cardiovascular disease and stroke: Obesity may be an independent risk factor for
coronary heart disease (CHD) with the degree of obesity being directly proportional
to the rate of development of CHD as you would also learn later in Unit 11. Even
moderate overweight has been shown to increase the risk of CHD. A reduction in
weight leads to improvement in cardiovascular risk factors like hypertension and
abnormal lipid levels. The blood pressure returns to normal and the lipid profile
improves.
When the blood vessels of the brain are diseased, they may rupture or there may be
inadequate blood supply to brain resulting in a stroke. This may be due to hypertension
or fatty deposits in blood vessels of the obese.
Type 1 Diabetes: In people with normal weight, Type1 Diabetes is not a major cause
of death but it is an important contributor to morbidity and mortality in obese people.
It is associated with insulin resistance and hyperinsulinaemia (increased level of
circulating insulin in blood). Fortunately, reasonable control in blood sugar levels may
be achieved by modification in the lifestyle. A balanced diet, physical activity and
drugs can control blood sugars and an obese can lead a near normal life.
Syndrome X : People with intra-abdominal obesity with high waist- to- hip ratio are
more prone to develop the metabolic syndrome X. This is characterized by the
collective presence of chronic disorders that include glucose intolerance, insulin
resistance, hyperlipidaemia and hypertension. The syndrome X is one of the major
public health problems associated with obesity.
Gall bladder disease: Obesity is one of the risk factors for formation of gallstones.
The supersaturation of bile with cholesterol in obese individuals makes them prone to
having gallstones as you will learn later in Unit 15. The excess adipose tissue is also
200 known to contain a large amount of cholesterol. Weight loss does not reduce the risk
of gallstone formation because the mobilization of adipose tissue may cause the bile Nutritional Care in
Weight Management
to become even more saturated with cholesterol in obese people.

Cancer: Risk of cancers of the colon, rectum and prostrate increases greatly in
obese men while obese women are more likely to develop cancer of breast, ovary,
endometrium and cervix.

Back pain, arthritis and gout: Abdominal obesity increases the risk of back pain
because of the extra load on the spinal column. This, in turn, reduces physical activity
leading again to an increase in adiposity.

Obesity is also associated with the development of osteoarthritis and gout. The extra
stress on the weight bearing joints is a contributing factor. Obese are prone to developing
hyperuricaemia (excess uric acid in blood) resulting in gout. We will learn more about
this later in Unit 13.

Infertility: Obese women are reported to suffer more from menstrual disorder,
infertility and polycystic ovary syndrome all of which tend to improve on reduction of
weight.

Sleep disorder: One of the common problems that obese males and females suffer
from is sleep disorder, commonly known as sleep apnoea. Obesity causes narrowing
of the upper airway when the person is in supine position. This can result in sudden
death in severe cases.

Psychological problems: Obese people may be exposed to ridicule and discrimination

in areas like employment, promotions and social interactions. This may result in low
self-esteem and depression leading to overeating for consolation. This aggravates the
existing problem further. Although it is increasingly being understood that obesity is a
complex interaction of metabolic, physiological, and genetic factors, obese people are
still viewed as being weak-willed and self-indulgent.

After a detailed study of various factors related to obesity, let us now move on to the
management and prevention of this multidimensional public health problem. In the
forthcoming section we shall discuss the strategies for achieving a negative energy
balance, as well as, the steps that must be considered for prevention of obesity.
However, let us first make an effort to check our understanding on the issues
discussed above.

Check Your Progress Exercise 2

1. State whether the following statements are true or false. Correct the false
statements.
a) When people are offered variety of foods, their intake is likely to be less
than when a single food is available.
b) Hyperthyroidism and Cushing’s Syndrome have obesity as one of their
characteristic features.
c) One kilogram dietary fat represents 9000 Kcals.
d) Losing and gaining weight by the obese throughout life cycle is termed
as the yo-yo effect.
e) Obesity predisposes to hypoinsulinemia and decreased glucagon levels.
f) Energy expended in physical activity is 60-75% of total energy
expenditure.
g) The Resting Metabolic Rate is regulated by the ob gene in human beings. 201
Clinical Therapeutic
Nutritio n 2. What is obesity? Enumerate the various etiological factors.
.................................................................................................................
.................................................................................................................
.................................................................................................................
3. Give reasons for the following:
a) An increase in weight gain is not directly proportional to an increase in
calorie intake.
...........................................................................................................
...........................................................................................................
...........................................................................................................
b) People lose weight rapidly in the beginning when they start following weight
reducing diets.
...........................................................................................................
...........................................................................................................
...........................................................................................................
c) A deficiency of leptin is conducive to obesity.
...........................................................................................................
...........................................................................................................
...........................................................................................................
4. Briefly discuss the metabolic aberrations of obesity?
.................................................................................................................
.................................................................................................................
.................................................................................................................
5. List the fatal, as well as, non-fatal conditions for which obesity is a risk factor.
.................................................................................................................
.................................................................................................................
.................................................................................................................

9.5 MANAGEMENT OF OBESITY

Management of obesity should be taken up with a clear understanding of the harsh
realities of the problem and its outcome. It may be a frustrating experience for the
physician and the nutritionist because of the frequent failures encountered during the
treatment. You have already read about multiple etiological factors causing the chronic
condition, the cause of which is difficult to pin-point. This makes the treatment even
more difficult. The lost weight is frequently regained by the obese which may be
demoralizing for continuing the necessary changes in the diet and physical activity.

Goals of treatment: As said in the beginning, the goal of treatment of obesity today
has shifted from mere ‘weight loss’ to ‘weight management’. Each weight loss
202 programme has to have its separate set of goals keeping in view the overall health of
the individual. A loss of as little as 5-10% of the original body weight by the obese Nutritional Care in
Weight Management
results in significant improvement of health and helps in reducing the severity of the
comorbidities or the risk factors associated with obesity. Studies have shown that
even with a 5-10% weight reduction, an obese has better glycemic control, and lowered
blood pressure and serum cholesterol levels. Hence it may not be realistic for the
obese to always have singular focus of coming down to the desirable weight. Obsession
with desirable weight may actually be inappropriate in some cases under certain
circumstances. So let us see what is the best approach to manage obesity.

9.5.1 Dietary and Lifestyle Modifications

The management of obesity basically comprises the following three- pronged approach.

a) Dietary modifications

b) Physical activity

c) Behaviour and lifestyle modifications

DIETARY
MODIFICATIONS

OBESITY
PHYSICAL BEHAVIOUR AND LIFE
ACTIVITY STYLE MODIFICATIONS

Figure 9.3: Management of obesity

Some cases where obesity is accompanied by certain comorbidities at higher BMI

values, the use of drugs and/or surgery may need to be considered. Pharmacological
and surgical interventions are required in relatively few cases and should not be
construed upon as substitute for necessary changes in diet and physical activity. We
shall deal with them individually a little while later in subsections 9.5.2 and 9.5.3
respectively. Let us begin our study with dietary management.
a) Dietary Modifications
The dietary modifications serve as a guide for the obese to make healthy food choices.
The first step towards prescribing a diet for weight reduction is to take a careful
dietary history of the obese person. You need to know the routine eating pattern, the
diet he/she is accustomed to, availability of foods and the likes and dislikes. Determine
the ideal weight from the height-weight tables given earlier in section 9.3. The daily
diet plan should have an energy deficit of 500-1000 Kcal in general. It is also important
for us to know whether the person has tried to lose weight earlier too and what
advice was given then and why was the outcome unsatisfactory. All this information
can be gathered in a few minutes and this could form the basis of providing appropriate
advice to the obese for losing weight. The following dietetic principles must be
considered while planning diets for weight reduction. Of course, you will be
learning more about this aspect in your practicals too. So let us learn about the dietary
guidelines.
Energy : Energy or calorie intake is the key factor which will determine the outcome
of dietary management for overweight/obese individuals. You will appreciate the fact
that to effect any degree of weight loss, the energy has to be restricted to the level
203
that enables mobilization of fat stores for carrying out the daily activities of the body.
Clinical Therapeutic The energy requirements can be determined on the basis of ideal body weight. Three
Nutritio n
main categories, depending upon the individual’s size and level of activities have been
determined on the basis of ideal body weight and have been mentioned in Table 9.5.

Table 9.5: Energy requirements based on activity levels for obese, normal
and underweight subjects

Energy Requirements* (Kcal/kg IBW/day)

Activity Obese Normal Underweight

Sedentary 20-25 30 35
Moderate 30 35 40
Heavy 35 40 45-50

Note: * refers to ±10% for small and large build.

Using the values given in Table 9.5, we can compute the energy requirements for
obese, normal and under weight adults for various levels of activity. Since the basal
metabolic rate is affected by the type of build, it is imperative to increase or decrease
the energy intake by 10% depending on the build (exomorphs and endomorphs,
respectively). However as a thumb rule or in the absence of data on height, the following
diets are often prescribed.

1. Moderate Deficit Diet (For pre obese) : 1400 Kcals/day and above for males
1200 Kcals/day for females is safe for
use

2. Low Calorie Diet (For obese): 800 to 1400 Kcals/day for males
800 to 1200 Kcals/day for females use
under medical supervision
3. Very Low Calorie Diet (For very obese) : Less than 800 Kcals/day use under
(VLCD) medical supervision

Despite calorie restriction, all the above diets must be nutritionally adequate. In general,
it is safe to use the moderate deficit diets providing 1200-1400 Kcals and low calorie
diets that provide minimum of 1000 calories/day. They can be planned to provide
optimum nutrition and offer sustainable weight loss. The VLCDs providing 400-800
Kcals/day on the other hand promote rapid weight reduction but must be followed
under close supervision of physician and dietician and that too, for a limited period of
12 to 16 weeks to minimize the risk of body protein losses and cardiac problems. They
may only be considered for the obese with a minimum BMI of 32.

REMEMBER IT IS SAFE TO USE MODERATE DEFICIT DIETS

PROVIDING 1200 -1400 KCALS/DAY. LOW CALORIE AND VERY LOW
CALORIE DIETS MUST BE USED UNDER STRICT MEDICAL CARE
FOR LIMITED PERIODS.

Proteins: Adequate amount of proteins should be included in the diet to ensure

proper metabolism and prevent weakness which is usually experienced by patients
after weight loss which is achieved by consuming an unbalanced diet. Protein rich
foods provide a higher satiety as compared to those rich in carbohydrates (other than
non-starch polysaccharides). Proteins also have a high specific dynamic action which
implies that their ingestion produces a greater increase in metabolism than ingestion of
carbohydrates or fats  an important aspect when you are trying to lose weight. Include
204
about 1g protein per kg body weight. Emphasis should be laid on the inclusion of Nutritional Care in
Weight Management
protein rich foods from plant origin rather than from animal sources as the former are
low in fat but high in dietary fibre.
Fats: Fats, being a concentrated source of energy need to be restricted. Excess
dietary fat promotes much more weight gain than carbohydrate or protein of the
same amount. Further, the gain in weight due to excess intake of fat is in the form of
adipose tissues which is not conducive to good health. Include fat in the form of
vegetable oils (rich in MUFA’s and PUFA’s) so that sufficient essential fatty acids
are supplied in the diet and at the same time the risk of developing coronary artery
disease can be minimized. Not more than 20% of the total energy should come from
fat. Foods rich in saturated fatty acids such as red meats, whole milk/its products
should be strictly avoided.
Carbohydrates: Carbohydrates in the form of non-starch poly-saccharides provide
bulk and satiety value to the reducing diet. They are also important for regular bowel
movements; constipation being a common problem among obese. About 50-55% of
total calories may be from complex carbohydrates and 10% from simple carbohydrates.
Include liberal amounts of fresh high fibre vegetables and fruits preferably raw and
with their edible peels in the diet.
Vitamins: If adequate amount of fresh fruits and vegetables are included in the diet,
the body stores of water soluble vitamins are usually not depleted. However when
we restrict fats for prolonged periods, the diet may be deficient in fat-soluble vitamins
A and D. They may need to be supplemented for the chronic cases.
Minerals: A diet high in sodium may promote retention of fluid in the body. Moderate
restriction in the use of common/table salt may be helpful in a weight reducing diet,
particularly if the patient is also hypertensive.
Fluids: Liberal amounts of water and zero/low calorie fluids may be included in the
diet. It may be helpful to have a glass of water before meal to reduce food intake.
Some patients benefit by taking a spoon of guar-gum/pectin/xanthum gum or finely
ground husk/bran of cereals and pulses in glass of water before meals as it gives a
feeling of satiety.
Mentioned below is an example of a weight reduction diet (1200 Kcal) along with a
sample menu to give you an idea regarding the applied aspects of the parameters
discussed so far.
EXCHANGE LIST FOR PLANNING 1200 KCAL DIET
Food Amount (approx.) CHO Protein Fat
per exchange (g) (g) (g) (g)
Milk 250 24 16 7.5
(double toned)
Vegetables 100-150 3.5 2 
Fruit 80-100 10  
Cereal 25 18.8 2.5 
Pulse 30 17 7 
Fat 5   5
This is just an idea given to you for calculating a 1200 Kcal diet. You will learn more
about food exchanges and planning of meals in the practical Manual (MFNL-005).
Below a sample menu for a day is given by using above exchange list:

205
Clinical Therapeutic Sample Menu for 1200 Kcal Diet
Nutritio n
Early Morning : Tea/coffee, Plain

Breakfast : 1 slice cracked wheat bread

2 slices tomato
1 egg white (boiled)
1 tsp. green chutney
2 tbsp. cornflakes
1 glass double toned milk
OR
2 spinach missi roti
1 medium bowl of curd
1 guava

Mid-morning : 1 orange
Lunch : 2 chapatties
1 bowl moong whole pulse
1bowl cabbage vegetable
1plate carrot and tomato
salad with lemon dressing
1 bowl curd (Double Toned)

Evening : Tea/coffee plain

Dinner : 1 cup clear vegetable soup
2 chapatties (wheat flour + soya flour)
1 bowl nutrinugget and pea vegetable
1 cucumber
1 bowl curd
Post Dinner : 1/2 cup milk
It will occur to you that the menu is simple home-made food which has less fat (3 tsp),
salt etc. but it is nutritious and filling. We know in a global scenario, a variety of foods
are available  Italian, Continental, Chinese, Thai and what not. Eating out is a fashion
and how we love it but you can imagine the calories that we add with yummy food.
Eating out is all right if done occasionally but missing the home food daily is not
advisable. Just see what it does to on individual slowly, gradually but surely – an early
affliction of degenerative diseases!
SIMPLE TASTY HOME MADE FOODS PROVIDE LESS CALORIES.
KNOWING THE CALORIES IN THE FOOD HELPS TO MAINTAIN
WEIGHT.
You may or would experience several times that overweight/obese patients attain
their lost body weight again and again particularly after leaving a weight reduction
programme. This generally happens due to inadequate counseling of the patient
regarding appropriate dietary habits. Proper dietary counseling gives the patient a
clearer understanding regarding the association of food with weight gain/loss. Behaviour
modification can result only through repeated counseling sessions and has therefore
been identified as a long-term approach for management of the achieved weight loss.
We shall now discuss some important aspects of diet counseling.
Diet Counseling
As discussed above diet counseling is a very important aspect of a successful weight
206 reduction programme. The person who attempts weight loss should be suitably motivated
and should be armed with facts related to the whole exercise. Counseling can be Nutritional Care in
Weight Management
given in person or to a group as you would recall studying in Unit 1. Individual counseling
is of prime importance because that is required to establish realistic goals for the
treatment so that you can relate to the diet and comply with the same. It is also
important to take the dietary history of the patient and to know about his food habits
and pattern of living for prescribing the diet schedule.
Group sessions have an importance of their own in the sense that they provide a
platform to people having similar problems to share their experiences and exchange
ways and means to bring about changes in their diets. The individuals are also likely
to be motivated better when they compare their progress with others in the group.
Both individual and group counseling are associated with motivation and psychological
support. There is no point in handing over a diet schedule to the patient unless he has
some motivation for losing weight. To bring about a change in dietary habits is not
easy because their foundation is laid in early infancy and childhood. You are not likely
to change unless you are strongly motivated to do so. Improvement or maintenance
of health is a very strong factor which the physician or dietician can use for motivating
the patient to bring about the necessary changes. With their guidance at initial and
follow up visits, this motivation can come from within the individual himself which will
see him/her through the programme successfully.
The patient should be very clear about the fact that excess calorie intake has to be
brought down to effect weight reduction. He/she also needs to understand the reasons
of overeating and how to control the factors leading to the same.
The counseling sessions help in increasing knowledge regarding food facts. The obese
may feel disheartened after a few weeks when they realize that the rate of weight
loss has decreased. The individual must understand that there is a reduction in
metabolic rate after some weight is lost. Despite careful adherence to the prescribed
schedule, the rate of weight loss will decrease. For weight loss to progress further
calorie restriction or increase in activity will be required, the latter is a better alternative.
Knowledge about calorie values of foods is another area which requires emphasis.
Food exchange lists which group different food items having approximately the same
calorie values are helpful in this regard. The individuals should know about portion
control to enable them to stick to the prescribed diet. Many foods have low calories
but when eaten in large portions contribute substantial calories in the diet. So how
much should the patient eat is also [Link] will learn more about food exchanges
in the practical (MFNL-005).
Instructions about eating out are important. An obese must select judiciously from
options available. For example any recipe that says cream of, creamy, buttered or
fried is bound to be high in calories. A clear soup, broiled or roasted non-vegetarian
dish or vegetables without sauces or thick gravies, salads without oily dressings and
fruit instead of a rich dessert are better options for them. Excess socialization hinders
the weight reduction programme. Eating light meals at home may be a good idea so
that the obese could minimize on extra calories.
b) Physical Activity
You are already aware that exercise plays an important role in initiating and sustaining
weight loss along with dietary and lifestyle modifications. Exercise promotes a sense
of well being and increases bone density, as well as, cardiovascular strength. It helps
in increasing the lean body mass in proportion to fat. Exercise burns glycogen stores
paving the way for fat to be used as fuel.
What is the effect of physical activity on health?
The Surgeon General’s report (1996) summarizes the effects of physical activity on
health as follows. 207
Clinical Therapeutic Overall Mortality: Higher levels of regular activity are associated with lower mortality
Nutritio n
rates among adults and even moderate activity on a regular basis results in lower
mortality rates than those who are least active. The risk of several degenerative diseases
is also reduced, as highlighted in Figure 9.4.

Physical Activity

Reduces the Risk

Cardiovascular Non Insulin Obesity Osteoporosis Cancer

Disease Dependent
Diabetes
Mellitus
Figure 9.4: Effect of physical activity on health

How much physical activity is enough?

Although it is difficult to prescribe the optimum amount of physical activity, it is important
to note that any exercise programme has to be consistent for affecting some degree
of weight loss. It is recommended that 30 minutes or more of moderate intensity
physical activity, even if accumulated in intermittent short spells at least five days a
week (preferably everyday) should form a daily routine of all adults. A single 30
minute stretch may have the first 5 minutes for warming up, 20 minutes of moderate
intensity exercise and 5 minutes of cooling down to prevent muscle injury. In any
exercise programme, intensity should be increased only gradually with professional
advice, especially for those who are above 40 years of age or have any health problems.
In general, it helps to take stairs instead of lift, to take the glass of water yourself
instead of asking somebody, walking to short distances instead of taking the car and in
general being a little more active than before.
The exercise selected by an individual should be pleasant, enjoyable, affordable and
easy to do. Practically speaking, the benefits of exercise besides its role in weight
management can be summed up as follows.
Exercise

* Reduces blood pressure

* Helps lessen angina pains
* Decreases body fats
* Increases HDL cholesterol
* Makes the heart stronger and more efficient
* Help in increasing bone density
* Reduces risk of cancers
* Increases longevity
* Offsets the immunity slump that accompanies aging

DAILY 30 MINUTES OR MORE OF MODERATE EXERCISE IS BEST FOR

MAINTAINING IDEAL WEIGHT, HEALTHY FEELING, LONGEVITY
AND GOOD IMMUNITY.
208
c) Behaviour and Life Style Modifications Nutritional Care in
Weight Management
Behaviour and life style modifications are an integral part of the weight reduction
plan. They are based on analysis of behaviour associated with appropriate, as well as,
inappropriate thinking and eating habits. The obese tend to overeat in certain situations
which if controlled may help towards keeping the weight in check. Keeping a food
diary, the act itself is associated with weight loss. This means that if an individual
pays attention to when and what he/she eats, they tend to eat less. It should not be
inferred from here that behaviour therapy avoids the need for restricting energy intake.
That still remains the mainstay of the treatment. The individual must learn to correct
the negative thoughts that accompany a dietary lapse, e.g., instead of thinking that ‘I
have wasted all my efforts, I ate a piece of cake today’, they should think ‘One slice
of cake is not going to increase my weight’. This shift of thought process helps
tremendously in continuing the effort to lose weight. The following strategies related
to lifestyle modifications are helpful. You may advocate these to obese individuals.

Remember:
 Have regular mealtimes. Irregular eating habits put a lot of strain on the body.
 Do not read or watch television while eating, you will land up eating more
than you do otherwise.
 Try to keep healthy snacks at home like fruits, vegetables and sprouts instead
of biscuits, cakes, fried snacks and other fast foods.
 Do not keep nibbling between meals. You will benefit by planning three main
meals with one mid-morning and an evening snack.
 Eat slowly, chewing the food properly.
 Serve smaller portions so that another helping can be taken.
 Avoid drinking of alcohol and smoking.
 Incorporate some amount of exercise in your daily routine.
 Handle stress in a positive manner through exercise, yoga and meditation.
Having looked at the dietary management, physical activity and lifestyle modification
next, let us briefly review the pharmaceutical and surgical management of obesity.
9.5.2 Pharmaceutical Management
A person with BMI 30 and above may require pharmaceutical management in addition
to dietary and lifestyle modifications. It may also need to be considered when the
obese person has associated problems such as impaired glucose tolerance,
dyslipidaemia and hypertension. Complications like severe osteoarthritis, obstructive
sleep dyspnoea etc. may also necessitate use of drugs. Let us get to know about
these drug.
Anti-obesity Drugs: The anti-obesity drugs can be classified into two broad groups
as indicated in the Figure 9.5.
Drugs
(Influencing)

APPETITE INTESTINAL ABSORPTION

(Promote Satiety and reduce appetite) (Decrease intestinal absorption)

1. Fluoxitena 1. Metformin
2. Ephedrine and Caffeine 2. Orlistat
3. Serotoninergic and nor-adrenenergic drugs
209
Figure 9.5: Anti-obesity drugs
Clinical Therapeutic Drugs must be taken only under Doctor’s advice as some can lead to side effects
Nutritio n
such as cardiac and liver problems. Herbal preparations must not be used as they lack
clinical evidence. Laxatives and diuretics are ineffective and liberal use of these can
affect the water and electrolyte balance of the patients body.
Caution should be practised in giving antiobesity drugs to patients undergoing psychiatric
treatment or those having any drug allergy. Their use is contraindicated for children
and pregnant and lactating women.

9.5.3 Surgical Management

Surgical procedures are generally restricted for the morbidly obese persons. If an
individual has a BMI of 40 or higher, or a BMI of 35 or higher with associated
comorbidities he/she may benefit by one of the surgical procedures. This specialized
area is known as Bariatric Surgery and includes the following procedures :
a) Gastric restrictive surgery
b) Jejunoileal Bypass
c) Jaw Wiring
d) Liposuction
Post-operative evaluation by the team of surgeons, dietician and psychologist at regular
intervals throughout life is of prime importance. Let us review the procedures.
 Gastric Bypass Surgery is the current ‘gold standard’ for bariatric surgical
procedures. It involves use of a stapling device to create a tiny stomach ‘pouch’
by partitioning the stomach near its upper end to reduce the capacity of the
stomach. On an average, the patient loses 30-40% of weight by this procedure.
The stomach size can also be reduced by using stainless steel staples across the
upper portion of the stomach. Only about l cm opening is left into the distal
stomach. This method is known as gastroplasty. This is found to be quite successful.
 Jejuno-ileal Bypass: Absorptive surface of the small intestines can also be
reduced through surgery called the jejuno-ileal by pass. Some complications may
arise by this method.
 Jaw Wiring: Wiring the jaws closed has been effective in reducing weight because
wiring permits the intake of only liquid that can be taken through a straw. Liquids
and supplements that will provide adequate nutrition are given.
 Liposuction: Liposuction is a cosmetic surgical procedure different from bariatric
surgery. It involves aspiration of subcutaneous fat using thin cannulas inserted
through very small incisions. The cannulas are attached to a high vacuum source
and fat is aspirated with a collection device. Contour is diminished as the
overlying skin shrinks to the reduced fat volume. Only 5 lb. of fat can be removed
at a time.
You have learnt how surgical methods are used in case of morbid obesity. Once the
treatment is done maintenance of appropriate weight is of prime importance. Let us
see how this can be done. The preventive aspects are discussed next.

9.5.4 Preventive Aspects

Maintenance of Weight Loss: Once an individual has managed to lose weight to a
desirable level, it must not be assumed that the weight loss will be maintained
automatically. The person will have to make a conscientious effort to prevent gain in
weight. You will recall that energy requirements are reduced after weight is lost.
After the intense dietary effort is over and the person reverts to the so called pre-
dieting eating pattern, he/she is likely to put all the weight back before equilibrium is
210
re-established.
To avoid this weight cycling, one must add extra food items to the diet only gradually Nutritional Care in
Weight Management
and with extreme caution. The person still needs to avoid high calorie recipes. He/she
must keep a record of weight every week. Any extra weight gained during this period,
however small, must be lost immediately either by reducing food intake or increasing
energy expenditure the following week. The person must not reduce the physical
activity once he/she attains the goal.
You must remember that there is a reduction in metabolic rate after weight loss which
is also conducive to subsequent weight gain on the same energy diet. To remain at the
target weight the person will need to, in fact, reduce energy intake by 10-15% which
is the maintenance energy cost of the weight lost.
Prevention in the prevalence of overweight/obesity: It is believed that the increase
in prevalence of obesity worldwide is more due to the environment that has become
conducive to weight gain rather than genetic mutations within individuals. As pointed
out earlier, Asian population is more susceptible to developing co-morbidities even at
quite modest weight gains. You must have fully understood by now that obesity is a
major risk factor for several chronic degenerative diseases. That is why it is all the
more important to employ strategies that aim at creating environments facilitating
behavioural changes in general populations regarding diet and physical activity to
prevent this enormous public health problem.
The first and most important step for the rapidly progressing developing countries like
India is to collect and organize data from various regions about the prevalence of
obesity. Once the true prevalence is known, the goals or targets to reduce the same
can be set. Let us consider towards whom the prevalence strategies need to be targeted.
The prevention strategies need to be targeted basically at two sub-groups in the
population.
i) Those who are already obese and need advice regarding reducing weight and
maintaining it. These persons, if not careful about their diet are liable to gain
weight. They need to be guided appropriately regarding a maintenance diet
because after a period of controlled eating, they tend to go back to their original
diet or favourite foods which may be high in energy and short on important
nutrients. All weight reducing clinics/community slimming centers must offer
appropriate guidance and support to people who have achieved weight loss
successfully to prevent regain in weight.
ii) Those who are at increased risk of becoming obese and require help to avoid
putting on weight. This is the major population group towards which public health
measures need to be targetted. It is believed that fitness at the age of 13 years is
quite a strong predictor of adult fitness. Children between the age of 7 and 12
years of age, therefore, may be a very important group that falls into this category.
In addition, it is important to develop strategies to prevent the population in general
from becoming obese. The major approaches of any public health strategy to reduce
obesity shall be firstly, to reduce calorie intake from fat and secondly, to increase the
level of physical activity.
How to reduce calorie intake from fat?
 Efforts should be made to increase the nutrition knowledge of the general public
through mass media.
 The foods with lower fat content should be made easily available and popularized.
 People should be motivated to make healthier food choices, especially when
eating out.
 Sincere efforts should be made by health professionals/systems to promote dietary
changes.
211
Clinical Therapeutic How to increase the levels of physical activity?
Nutritio n

 The benefits of physical fitness should be spread among the public through mass
media.

 Physical activity should be encouraged in educational and other institutions.

 Opportunities for physical activity should be provided at work places and industry.

 Public facilities for physical activity and exercise should be increased.

National Approach - An Example

A number of countries have adopted a national approach to deal with the prevention
of obesity and other non-communicable diseases. At a symposium on ‘Obesity’ at the
IX Asian Congress of Nutrition, in 2003, Mabel Deurenberg-Yap of National University
of Singapore discussed the health promotion strategies to reduce obesity in her small
and highly urbanized country, Singapore. Singapore had initiated National Healthy
Lifestyle Programmes and School Health Promotion Programmes twenty years ago
to promote healthy eating and active life styles with a view to reduce the risk factors
associated with lifestyle related non-communicable diseases. Strong governmental
support, as well as, consistent effort by the organizers has resulted in reducing obesity
rates today, particularly among children. Adults have also been highly motivated to
engage in physical activity. The government has developed a number of parks and
swimming pools at short distances near residential areas to facilitate participation in
aerobic exercises and games. Schools besides classroom teaching have special emphasis
on sports and outdoor exercises.

Evaluation of these programmes to reduce obesity is regularly being carried out in

order that they may be improved upon and may become more effective. Special
emphasis is also given to health promotion research and evaluation. The country has
been successful in setting an example which other nations must try to emulate.

Check Your Progress Exercise 3

1. How can one manage obesity? Briefly discuss the dietary guidelines for an
obese individual.
..............................................................................................................
..............................................................................................................
..............................................................................................................
2. Discuss the role of individual counseling in a weight reduction programme.
..............................................................................................................
..............................................................................................................
3. Enumerate the benefits of exercise/physical activity on CVD.
..............................................................................................................
..............................................................................................................
4. What are the two broad categories of antiobesity drugs? For whom are these
contraindicated?
..............................................................................................................
..............................................................................................................

Now that we are well versed with obesity and its medical nutrition therapy, we move
212 on to underweight the other weight management issue.
 Nutritional Care in
9.6 UNDERWEIGHT Weight Management

Just as overweight is the result of a positive energy balance irrespective of the etiology,
underweight results when the energy balance is negative. Failure to consume sufficient
calories to meet the energy requirement of the body for whatever reasons is responsible
for not maintaining optimum weight. You have learnt that too much deviation on either
side from the appropriate body weight increases the risk of health problems. You may
also recall reading earlier about the prevalence and classification of underweight in
section 9.2 of this unit while we were discussing the prevalence of weight imbalance.
In addition, it is relevant to note that as per the report of WHO (1998), an estimated 50
million adult women are classified as being severely underweight in developing countries.
It also states that the consequences of poor health in childhood and adolescence including
malnutrition, become apparent in adulthood, particularly during the childbearing years.
At the IX Asian Congress of Nutrition (2003), Z.A. Bhutta, Pakistan reported that
adult women who suffer from malnutrition had a much higher risk of giving birth to
low birth weight (LBW) infants. LBW infants are at a higher risk of mortality. Those
who survive are poorly breastfed and weaned, resulting in stunted, malnourished
children. Additionally, LBW females developed into malnourished mothers who in
turn gave birth to LBW infants. He stressed that this cycle could only be broken by
optimizing nutrition throughout the life cycle. So then the adverse consequences of
underweight are [Link], what is the cause for this condition? Let us read the
next section and find out.

9.6.1 Etiology
There are a number of factors causing underweight. These are:
 Poor selection of food
 Physical activity
 Mother’s health status
 Pathological condition
 Genetic predisposition
Let us learn a little about each of these factors.
 Poor Selection of Food: Poor selection of food along with irregular eating habits
may be responsible for insufficient food intake and hence calorie intake. It may
be due to ignorance or a lack of purchasing power of the family.
 Physical Activity and Psychological Factor: Individuals who are tense, nervous
and extremely active and who do not rest sufficiently tend to expend more energy
than what they are able to eat. This can cause undernutrition.
 Mother’s Health Status: Poor nutritional status of the girl child coupled with
under nutrition during pregnancy results in LBW infant being born. These children
born are at a disadvantage right from infancy and may fail to reach optimum
weight in adulthood.
 Pathologic Conditions: Illness can affect weight status in a number of ways.
For example, fevers and infections, increase the demand for energy, which if not
met because of poor appetite, lead to loss of weight. Food intake may be severely
limited by nausea, vomiting or diarrhoea in gastrointestinal disturbances. Metabolic
rate may be greatly increased in hyperthyroidism resulting in underweight. Drug
therapy may also alter taste or reduce appetite, leading to weight loss.
 Genetic Predisposition: As explained in section 9.2 of this unit, the weight of
an individual is inherited basically from his biological mother. In the event of
the biological mother being thin, there is 75% likelihood of the individual being
213
thin also.
Clinical Therapeutic Next, let us review the metabolic aberrations and clinical manifestations linked with
Nutritio n
underweight.

9.6.2 Metabolic Aberrations and Clinical Manifestations

Metabolic Aberrations: When energy intake falls below the minimal requirements,
the body responds with an orderly physiologic adaptation involving the hormones of
energy metabolism. This causes mobilization of free fatty acids from adipose tissues
and of amino acids from muscle to provide energy. Protein synthesis is cut down
because proteins are burnt up for providing energy to the body. The metabolic rate of
the body is reduced and lean body mass and adipose tissue contract resulting in
weight loss.

Undernutrition is generally accompanied by protein deficiency in the body. Fortunately,

the condition is reversible with proper nutritional support.

Changes in Body Tissue Compartments: The severity of nutritional deprivation

determines the extent of changes in the body tissue compartments. The first casualties
in moderate undernutrition are mainly the visceral proteins and muscle cell mass without
any change in body fat. In severe undernutrition, losses of both muscle cell mass and
body fat occur to a significant degree. Anthropometric measures and laboratory
determination of protein status can predict the extent of changes in the body tissue
compartments.

A number of micronutrient deficiencies may occur in individuals who are underweight

because of the less quantity of food ingested. A starving patient has inelastic skin,
slow pulse, low blood pressure, marked emaciation and progressive loss of weight.

Clinical Manifestations: Underweight may predispose to fatigue, lethargy and

breathlessness. Iron-deficiency anaemia is usually seen because the diet is bound to
be deficient in iron at a low intake of food. The accompanying protein deficiency, if
severe, may manifest itself in the form of oedema. Underweight individuals are likely
to suffer repeatedly from infection because of low immunity. Hip fracture is often
preceded by weight loss. Metabolic aberrations occur during starvation and these
may cause bradycardia (slow pulse), hypotension (low blood pressure), constipation,
dry skin and hair, abnormalities of nervous system, depression and ultimately death.

So what can we done to prevent these manifestations. The dietary management is

highlighted next.

9.6.3 Dietary Management

We just read about the etiological factors that may lead to undernutrition and
weight loss. Whatever may be the cause, all underweight individuals are usually in a
negative energy balance and have depleted reserves of most nutrients. The diet
prescribed for effecting weight gain should be high in calories, proteins, fat and
carbohydrates. Since the capacity of the intestines to digest and absorb food is
considerably reduced with undernutrition, the addition of foods above the usual intake
has to be slow and gradual. We shall now discuss some of the salient features of a
weight gain diet for individuals not suffering from any form of chronic disease that
requires restrictions in the nutrient intake. So, let us start with the calorie intake which
is most significant to weight gain.

Energy: The total calorie intake should be 500 to 1000 Kcal in excess of the daily
needs in order to result a gain in weight by half to one kilogram in a week. Thus, if you
need 2000 Kcal for your normal activity, you require 2500-3000 Kcal per day for
weight gain. We can also compute the energy requirements on the basis of ideal
body weight (as discussed in subsection 9.5.1 of this unit). The patient may be given
30-35 Kcal per Kg ideal body weight per day. The calories should be increased
gradually over a period of one or two weeks to avoid digestive disturbances.
214
Proteins: Proteins are required for tissue building, as well as, to take care of the daily Nutritional Care in
Weight Management
wear and tear. Under weight individuals generally have depleted lean body mass and
poor reserves of amino acids/blood proteins. Thus, the patient may benefit by
consuming around 1.2 g per kg body weight of proteins per day. A combination of
both animal and plant proteins should be incorporated but emphasis should be laid on
the inclusion of easy to digest forms of protein such as half boiled egg, steamed/
boiled/sautéed flesh food etc.
Fats: We know that fats are concentrated source of energy (1g = 9 Kcals). Fats are
capable of increasing the energy value of the diet without adding much bulk to it. Add
extra fat gradually, a sudden increase in fatty foods like butter, cream and oil may
produce diarrhoea. About 30% of calories should come from unsaturated sources of
fat.
Carbohydrates: Liberal amounts of easy to digest carbohydrates should be included
in the diet. The intake of dietary fibre should be minimized so as to prepare meals
which are nutrient dense and have a small volume. Include more of high calorie
vegetable like potatoes, colocasia and yam instead of raddish, cucumber, leafy
vegetables which are low in the carbohydrate content. All cereals provide high calories
at low cost. Carbohydrates should provide about 60-65% of total kilocalories.
Vitamins and Minerals: If the diet provides good amounts of fresh fruits and
vegetables, vitamin or mineral supplements are usually not required. However, if the
patient indicates clinical signs of a severe nutritional deficiency, it may be imperative
to use supplements or employ other essential medical measures.
Fluids: Take fluids only after a meal instead of with or before meals so that food
intake is not reduced. High calorie nourishing beverages such as milk shakes, egg nog
should be preferred over low nutrient beverages such as cold-drinks, barley water,
plain soda etc.
Planning the Daily Diet
As mentioned above you need to add calories gradually to the diet. A practical way
of doing so is to take the present intake of the patient and to improve upon it both
qualitatively and quantitatively day by day till you reach the prescribed level. Try to
add foods from most of the food groups. You can add 500 Kcal to the diet by including
any of the following combinations

Whole milk : 1glass (250ml)

Boiled egg : one
Bread : one slice
Banana : one
OR

Chapatties : 2
Dal : 1 bowl (30 g raw)
Cottage cheese : 40 g
Sapota : One

OR

Fried Rice : 1 bowl (30 g raw)

Curd(whole milk) : 1 bowl (100 g)
Ice cream with fruits : 1 cup
The patient should be advised to take small, frequent, easy to digest meals. As the
person improves in weight without having any gastrointestinal problems, he/she could
215
take calorie-rich foods. You will learn how to select high calorie foods and plan diets
Clinical Therapeutic for ambulatory and hospitalized patients to promote weight gain in the Practical Manual
Nutritio n
(MFNL-005).
SELECT CALORIE-RICH FOODS. INCREASE THE SERVINGS OF
FOODS GRADUALLY. EAT FREQUENTLY. ENJOY THE FOODS YOU
LIKE IN A HAPPY ENVIRONMENT.
The subject of weight management is vast and has unending diverse applications in
the management of individuals with/without an underlying disease condition. We end
our discussion here within the parameters of this unit but strongly recommend additional
reading to clear your views on various food fads and misbeliefs. Let us now attempt
the questions mentioned in check your progress exercise 4 to recapitulate the contents
of this section.
Check Your Progress Exercise 4
1. Fill in the blanks:
a) A BMI value of less than ............................. denotes underweight.
b) Protein deficiency is ............................. when proper nutritional support
is provided to underweight individuals.
c) A starving patient has ....................pulse and.....................blood
pressure.
d) Malnutrition in adult women can be a risk factor for birth of.....................
infants.
e) 1gram fat provides ............................. Kcal of energy.
2. List three pathological conditions that may contribute to underweight.
.................................................................................................................
.................................................................................................................
.................................................................................................................
3. How can you add 500 Kcals to the diet of an underweight individual? Give one
example.
.................................................................................................................
.................................................................................................................
.................................................................................................................

9.7 LET US SUM UP

It must have been an interesting unit to read because we all are interested in maintaining
an ideal body weight and also because this topic has a wide applied aspect. For this
reason; we have also designed a partical (Manual-005) for you to learn the use/planning
of diet(s) based upon maintenance of an optimum body weight espeialy with respect
to various diseases.
In this unit we learnt about weight imbalance and the difference between different
grades of under/excess body weight. The metabolic and clinical manifestations of
both under and overweight were also discussed (impaired glucose tolerance,
hyperinsulinemia, insulin resistance, hyper-lipidemia etc.). In the section 8.5 you must
have learnt about the dietary and life-style management for over weight/underweight
individuals. Read this carefully as the fundamentals of these are utilized for effective
and accurate planning of diet(s) for such individuals with or without a disease (diabetes,
coronary artery disease(s), cancer; gout; fever etc.). The physiological effects of
216 increased physical activity were also briefed in this unit. Nutrition supports and non-
dietary (surgical, pharmaceutical), measures with respect to weight management are Nutritional Care in
Weight Management
gaining in roads for the treatment of secure obesity and a dietician’s help is often
required for ensuring optimum nutritional care of the patient. Reading this unit must
have helped you in gaining an insight/better understanding on the various aspects of
weight management.

9.8 GLOSSARY
Arthritis : a disease that involves an inflammation of a joint or
joints.
Bariatric Surgery : surgical procedures for treatment of obesity.
Bariatrics : a scientific study of obesity and its related disorders.
Binge eating : an episode of excessive eating accompanied by a sense
of loss of control over the eating process.
Borborygmi : abdominal gurgles due to movement of excessive fluid
and gas in the intestines.
Brown Fat : a dark-coloured, mitochondrion-rich adipose tissue in
many mammals that generates heat to regulate body
temperature.
Carotenemia : presence in the blood of yellow pigment carotene from
excessive intake of carotene rich vegetables and fruits.
Comorbidity : any condition that worsens as the degree of obesity
increases and improves as obesity is successfully
treated.
Cushing’s syndrome : a glandular disorder caused by excessive steroid
hormone resulting in greater than normal functioning
of adrenal gland; characterized by obesity.
Hirsutism : an excessive growth of coarse hair particularly in
women.
Hypercholesterolaemia : elevated blood cholesterol levels.
Hyperplasia : an increase in tissue size by an increase in number of
cells.

Hypertriglyceridaemia : elevated level of serum triglycerides.

Hypertrophy : an increase in tissue size by an increase in cell size.

Hyperuricaemia : elevated serum uric acid levels.

Life expectancy : a statistical measure of the average of the remaining

life time of an individual in the given group.

Lipogenesis : fat formation.

Liposuction : the removal of excess body fat by suction with

specialized surgical equipment.

Morbidly obese : patient’s who are 0-100 % above their ideal body weight;
a BMI value greater than 39.

Obesity : a condition describing excess body weight in the form

of fat. 217
Clinical Therapeutic Osteopaenia : a decrease in the bony mass due to a decreased rate of
Nutritio n
osteoid (organic matrix bone) synthesis.
Osteoporosis : loss of bony tissue resulting in bones that are brittle and
liable to fracture.
Overweight : being too heavy for one’s height; a BMI of 25 to 30
kg/m2
Quality of life : the level of well being of life style and the physical
conditions in which people live.
Resting Metabolic Rate : the minimum number of calories needed by the body to
support its basic physiologic functions.
Syndrome X : a condition associated with glucose intolerance, insulin
resistance, hyperlipidemia and hypertension, strongly
linked to fat accumulation in the intra-abdominal cavity.

9.9 ANSWERES TO CHECK YOUR PROGRESS

EXERCISES
Check Your Progress Exercise 1
1. a) 200, 338
b) 5
c) 64.5 and 30.5
d) upper middle
e) 1.0, 0.85
2. a) A person can be categorized to be overweight /obese by computing the
body mass index or the waist hip ratio.
Body Mass Index (BMI) is calculated as:

Weight (in kg)

BMI =
Height (in meters)2

b) A body mass index greater than 25 in indicating of over weight/obesity.

Waist circumference (cm)
Waist hip ratio i.e.
Hip cirumference (cm)
WHR of >1.0 for men and >0.85 for women is an indicator of adbominal
obesity.
3. Age, sex and height are the three essential factors that determine an individual’s
ideal body weight.
4. i) - b)
ii) - a)
iii) - d)
iv) - c)
v) - e)
218
Check Your Progress Exercise 2 Nutritional Care in
Weight Management
1. a) False. When people are offered a variety of foods, their intake is likely to
be more than when a single food is available.

b) True

c) True

d) True

e) False. Obesity predisposes to hyperinsulinemia and increased glucagon levels

f) False. Energy expended in physical activity is 15-30% of total energy

expenditure.

g) False. Resting Metabolic Rate is regulated by the 3 adrenoreceptor gene

in human beings

2. Obesity is a physiological condition resulting from accumulation of excess adipose

tissue i.e. body fat. The etiological factors are: genetic susceptibility, dietary
habits, reduced physical activity, increasing affluence and abundant availability
of food, psychological factors, hormonal imbalance, high birth weight and
childhood growth pattern.

3. a) Firstly, as the quantity of food ingested is increased, thermogenic effect of

food would also increase amounting to about 10% of the excess intake.
Secondly, the energy stored would increase both the fat and the fat-free
mass resulting in an increase in metabolic rate. This adaptation of metabolic
rate which tends to oppose fluctuation in weight does not permit weight
gain in direct proportion to increase in calorie intake.

b) Initially, glycogen stores are mobilized which is accompanied by a

corresponding loss of water. Then, as weight is lost, it results in loss of
extra muscle which was developed to support the extra adipose tissue.
Loss of lean body mass reduces the RMR rapidly so that on a given diet,
the energy deficit is reduced and the rate of weight loss slows down.

c) WAT is an endocrine organ, which besides some other factors secretes a

hormone leptin. Leptin seems to have a role to play in reducing appetite or
increasing satiety and also in regulation of the energy balance.

4. Metabolic aberration seen are deranged lipid profile insulin resistance,

hyperinsulinaemia etc. Read subsection 9.4.3 and write brief account for each
in your own language.

5. The fatal risk factors for obesity include: cardiovascular disease, diabetes mellitus,
cancer, syndrome X, arthritis and gout. Some non-fatal conditions like back pain,
infertility, sleep disorders and respiratory conditions may also be seen.

Check Your Progress Exercise 3

1. The management of obesity basically comprises of the three-pronged approach.
These are: dietary modifications, physical activity, and behaviour and lifestyle
modifications.

Dietary guidelines for an obese include 1g protein per kg body weight. About
25% or less of total calories should come from fat. About 50-55% of total calories
may be from complex carbohydrates, mostly plant-based. Vitamin supplements
should be given in case of long duration calorie restriction . A diet high in sodium
may promotes retention of fluid in the body. Liberal amounts of fluid may be
included in the diet if salt is restricted. 219
Clinical Therapeutic 2. Individual counseling is of prime importance because that is required to establish
Nutritio n
realistic goals for the treatment. It is also important to take the dietary history of
the patient and to know about his food habits and pattern of living for prescribing
an adaptable diet schedule.

3. The benefits of exercising are that it reduces blood pressure, decreases harmful
body fats, increases HDL cholesterol, help in increasing bone density, reduces
risk of all types of cancers significantly and increases longevity.

4. Two types of anti-obesity drugs are (i) appetite suppressants, and (ii) intestinal
absorption suppressants. These drugs are contraindicated for children, pregnant
and lactating women and patients who have had adverse effects from such
drugs in the past.

Check Your Progress Exercise 4

1. a) 18.5
b) reversible
c) slow, low
d) LBW
e) 9
2. The three pathological conditions that can contribute to underweight include,
recurrent infection, fever, chronic diarrohoea/ulcers, degenerative diseases such
as cancer.
3. Answer on your own. Look up sub-section 9.6.3 for reference.

220