Kevin R. Fontaine

Obesity and health-related quality of life.

Although it is well documented that obesity is strongly associated with morbidity and mortality, less is known about the impact of obesity on functional status and health‐related quality of life (HRQL). However, in recent years research has been conducted to estimate the impact of obesity on HRQL, and to determine the effects of weight reduction on HRQL. The majority of published studies indicate that obesity impairs HRQL, and that higher degrees of obesity are associated with greater impairment. Obesity‐associated decrements on HRQL tend to be most pronounced on physical domains of functioning. Studies of the effect of obesity surgery among morbidly obese patients indicate that this procedure produces significant and sustained improvements in the majority of HRQL indices; among mild‐to‐moderately obese persons, modest weight reduction derived from lifestyle modification also appears to improve HRQL, at least in the short term. Additional research is needed to (1) further characterize the effect that obesity has on HRQL; (2) estimate the short‐ and long‐term effects of various methods of weight reduction (e.g. surgery, lifestyle modification) on HRQL; (3) improve both the conceptualization and measurement of HRQL to incorporate the personal preferences and values of the patient; and (4) develop ways to enhance and sustain positive changes in HRQL, even if weight maintenance is elusive.

Putative contributors to the secular increase in obesity: exploring the roads less traveled

Objective:To investigate plausible contributors to the obesity epidemic beyond the two most commonly suggested factors, reduced physical activity and food marketing practices.Design:A narrative review of data and published materials that provide evidence of the role of additional putative factors in contributing to the increasing prevalence of obesity.Data:Information was drawn from ecological and epidemiological studies of humans, animal studies and studies addressing physiological mechanisms, when available.Results:For at least 10 putative additional explanations for the increased prevalence of obesity over the recent decades, we found supportive (although not conclusive) evidence that in many cases is as compelling as the evidence for more commonly discussed putative explanations.Conclusion:Undue attention has been devoted to reduced physical activity and food marketing practices as postulated causes for increases in the prevalence of obesity, leading to neglect of other plausible mechanisms and well-intentioned, but potentially ill-founded proposals for reducing obesity rates.

Ten Putative Contributors to the Obesity Epidemic

The obesity epidemic is a global issue and shows no signs of abating, while the cause of this epidemic remains unclear. Marketing practices of energy-dense foods and institutionally-driven declines in physical activity are the alleged perpetrators for the epidemic, despite a lack of solid evidence to demonstrate their causal role. While both may contribute to obesity, we call attention to their unquestioned dominance in program funding and public efforts to reduce obesity, and propose several alternative putative contributors that would benefit from equal consideration and attention. Evidence for microorganisms, epigenetics, increasing maternal age, greater fecundity among people with higher adiposity, assortative mating, sleep debt, endocrine disruptors, pharmaceutical iatrogenesis, reduction in variability of ambient temperatures, and intrauterine and intergenerational effects as contributing factors to the obesity epidemic are reviewed herein. While the evidence is strong for some contributors such as pharmaceutical-induced weight gain, it is still emerging for other reviewed factors. Considering the role of such putative etiological factors of obesity may lead to comprehensive, cause specific, and effective strategies for prevention and treatment of this global epidemic.

Myths, Presumptions, and Facts about Obesity

BACKGROUND Many beliefs about obesity persist in the absence of supporting scientific evidence (presumptions); some persist despite contradicting evidence (myths). The promulgation of unsupported beliefs may yield poorly informed policy decisions, inaccurate clinical and public health recommendations, and an unproductive allocation of research resources and may divert attention away from useful, evidence-based information. METHODS Using Internet searches of popular media and scientific literature, we identified, reviewed, and classified obesity-related myths and presumptions. We also examined facts that are well supported by evidence, with an emphasis on those that have practical implications for public health, policy, or clinical recommendations. RESULTS We identified seven obesity-related myths concerning the effects of small sustained increases in energy intake or expenditure, establishment of realistic goals for weight loss, rapid weight loss, weight-loss readiness, physical-education classes, breast-feeding, and energy expended during sexual activity. We also identified six presumptions about the purported effects of regularly eating breakfast, early childhood experiences, eating fruits and vegetables, weight cycling, snacking, and the built (i.e., human-made) environment. Finally, we identified nine evidence-supported facts that are relevant for the formulation of sound public health, policy, or clinical recommendations. CONCLUSIONS False and scientifically unsupported beliefs about obesity are pervasive in both scientific literature and the popular press. (Funded by the National Institutes of Health.).

Depressive mood and obesity in US adults: comparison and moderation by sex, age, and race.

Objective:Sustained depressive mood is a gateway symptom for a major depressive disorder. This paper investigated whether the association between depressive mood and obesity differs as function of sex, age, and race in US adults after controlling for socio-economic variables of martial status, employment status, income level and education level.Methods:A total of 44 800 nationally representative respondents from the 2001 Behavioral Risk Factor Surveillance Survey were studied. Respondents were classified as having experienced a depressive mood if they felt sad, blue, or depressed at least for 1 week in the previous month. The depressive mood was operationalized in terms of duration and sustenance, both defined based on number of days with depressive mood: 7+ and 14+ days. Age groups were classified as young (18–64 years) and old (65+ years). Obesity status was classified as: not overweight/obese (BMI<25); overweight (25⩽BMI<30); obese (BMI⩾30).Results:Prevalence of prior-month depressive mood was 14.3 and 7.8% for 7+ and 14+ days, respectively. Controlling for race and socio-economic variables, both young overweight and obese women were significantly more likely to have experienced depressive mood than nonoverweight/nonobese women. Young overweight, but not obese, men were significantly more likely to have experienced depressive mood than nonoverweight/nonobese men. Young obese women were also significantly more likely to have a sustained depressive mood than nonoverweight/nonobese women. For old respondents, depressive mood and its sustenance were not associated with obesity in either sex.Discussion:The relationship between the depressive mood and obesity is dependent upon gender, age, and race. Young obese women, Hispanics in particular, are much more prone to depressive mood than nonobese women. Future studies testing associations between depression and obesity should be sensitive to the influence of these demographic and socio-economic variables.

Can inexpensive signs encourage the use of stairs? Results from a community intervention.

The American Heart Association recently added a sedentary lifestyle to its list of modifiable risk factors [1]. Reports suggest that only 22% of the U.S. adult population are active enough to derive health benefits from their physical activity and that one in four Americans are completely sedentary [2]. This finding may parallel the sharp increase in the prevalence of overweight persons over the past 12 years, from 25% in the National Health and Nutrition Examination Survey (NHANES II) in 1976-1980 to 33% in phase I of NHANES III in 1988-1991 [3]. The Centers for Disease Control and Prevention and the American College of Sports Medicine recently revised their recommendation regarding exercise to suggest that all Americans should accumulate 30 minutes or more of moderate-intensity physical activity on most or all days of the week [4]. Inactive people who increase their levels of physical activity are less likely to die of all causes and of cardiovascular disease than those who remain sedentary [5, 6]. Walking and taking the stairs instead of escalators or elevators may be two easy ways for seemingly healthy sedentary adults to become more moderately active [7-10]. In 1980, Brownell and associates [11] examined the effects of placing a sign that encouraged stair use for health benefits at the base of an escalator that was adjacent to a flight of stairs in a mall, train station, and bus terminal in Philadelphia. They reported that the sign resulted in statistically significant increases in stair use among 45 694 commuters. They also noted that overweight persons did not use the stairs as often as leaner persons before or after the sign was erected. Blamey and colleagues [12] recently examined the effects of encouraging stair use for health benefits in a Scottish train station and also found that a low-cost sign could result in statistically significantly increases in stair use by adults. We examined the trends among shoppers of different ages, ethnicities, sexes, and body weights in a shopping mall in which escalators and stairs were adjacent. We also observed the differential effects of adding signs at the base of the escalator that promoted stair use for health benefits or weight control. Methods Participants We observed 17 901 adult patrons of a mall located in a Baltimore suburb while they used the stairs or escalators. Because of the potential for artifactual influence on the decision process, persons carrying items larger than a briefcase were excluded. We also excluded persons carrying a baby or child and those judged to be younger than 18 years of age. Participants were unaware that they were part of a study investigating physical activity patterns. Design This observational study involved an initial baseline phase and two subsequent intervention phases that incorporated motivational signs displayed at the base of the escalator and stairs. Each of the three phases lasted 1 month. During the baseline phase, the frequency of stair use compared with use of the adjacent escalator was recorded. During the first interventional phase (health benefits), a 22 28 sign was placed on an easel beside the escalator and stairs. The sign featured a caricature of a heart at the top of a flight of stairs and the statement, Your heart needs exercise, use the stairs. During the second interventional phase (weight control), a similar-sized sign was placed on an easel. The sign featured a caricature of a woman at the top of a flight of stairs; she had a thin waistline and was wearing pants with a waist that was too large. The caption on the sign read, Improve your waistline, use the stairs. Setting In this suburban Baltimore mall, participants could use the escalator or the stairs to get to the second floor. A stairway was adjacent to ascending and descending escalators. The stairway consisted of 10 stairs, a 6-foot landing, and 10 more stairs. Observations were made during June, July, and August between 10:30 a.m. and 9:00 p.m. on all days of the week. Procedures Observations were made by one of the authors. A previous physical activity study [11] used many observers to ensure valid observation of all persons. However, the volume of mall traffic was never so heavy that more than one observer was needed to code the characteristics and choice of each person. Before the study began, the observer and the senior author spent one full day in the mall classifying shoppers by age and weight status to be sure that observations were as accurate as possible. The observer sat in an inconspicuous spot at the foot of the steps that allowed for clear observation. Frequency of stair use was recorded in the same way during each of the three phases. Each persons sex and ethnicity (black, white, or other) was recorded. In addition, persons were judged to be 40 years of age or older or younger than 40 years of age. Finally, the observer noted whether the person appeared overweight. Statistical Analysis The change in proportions of persons using the stairs from the baseline to the intervention phases of the study was analyzed by using the chi-square test and by computing 95% CIs around the differences in proportions between the comparison groups. The same procedure was used to examine intergroup differences (normal weight or overweight) within a given phase of the study. We also computed the number needed to treat (NNT), the number of shoppers who needed to be exposed to the sign to get one shopper to use the stairs, as 1/RD, where RD is expressed as the difference in proportions between the two comparison groups. Results are presented as the proportion of persons who opted to use the stairs rather than the escalator; 95% CIs are presented with associated P values and the NNT. Data were analyzed by using the SPSS for Windows (version 8.0) statistical package [13]. Results A total of 17 901 observations were made. Overall, the use of stairs at baseline was 4.8%. During the intervention period when the health benefits sign was displayed, stair use increased significantly to 6.9% (difference, 2.1 percentage points [CI, 1.3 to 2.8 percentage points]; NNT, 48). Compared with the baseline value, stair use also increased significantly to 7.2% when the weight-control sign was displayed (difference, 2.4 percentage points [CI, 1.5 to 3.2 percentage points]; NNT, 42). Stair use did not differ between the health benefits (6.9%) and the weight-control (7.2%) signs (difference, 0.3 percentage points [CI, 0.5 to 1.2 percentage points]; NNT, 333). Sex Table 1 and Table 3 shows the percentage of persons who used the stairs during the studys three phases as a function of age, sex, race, and body weight. Table 2 shows the change in stair use with the two signs and the change from the health benefits sign to the weight-control sign. A similar pattern emerged among men and women: Compared with baseline levels of stair use, both the health benefits sign and the weight-control sign increased stair use from 4.9% to 7.2% and 7.4%, respectively, among women and from 4.8% to 6.4% and 7.0%, respectively, among men). No sex-related differences were found when no sign or either type of sign was present. Table 1. Stair Use before and during Placement of Two Different Motivational Signs Table 3. Table 1 Continued Table 2. Changes in Stair Use among Groups of Shoppers in Response to Signs Promoting Stair Use Age At baseline, 4.6% of persons judged to be younger than 40 years of age used the stairs. Six percent took the stairs with the display of the health benefits sign (difference, 1.4 percentage points [CI, 0.3 to 2.4 percentage points]; NNT, 71), and 6.1% took the stairs in response to the weight-control sign (difference, 1.5 percentage points [CI, 0.3 to 2.7 percentage points]; NNT, 66), significantly increasing stair use relative to the baseline value (P = 0.015). No statistically significant difference in stair use was found between the health benefits sign and weight-control sign (difference, 0.1 percentage points [CI, 3.4 to 3.6 percentage points]). A similar pattern emerged among persons judged to be 40 years of age or older. At baseline, 5.1% of persons took the stairs; when the health benefits sign was erected, 8.1% chose to climb the stairs (difference, 3.0 percentage points [CI, 1.7 to 4.3 percentage points]; NNT, 33), and the weight-control sign increased stair use to 8.7% (difference, 3.6 percentage points [CI, 2.1 to 5.1 percentage points]; NNT, 28). Stair use did not significantly differ between the two signs (difference, 0.6 percentage points [CI, 0.8 to 2.1 percentage points]). Older shoppers were more likely than younger shoppers to take the stairs in response to both the health benefits sign (difference, 2.1 percentage points [CI, 0.9 to 3.2 percentage points]) and the weight-control sign (difference, 2.6 percentage points [CI, 1.1 to 4.1 percentage points]) (Figure 1). Figure 1. Patterns of stair use among shoppers judged to be younger than 40 years of age (white bars) or 40 years of age or older (striped bars). Body Weight Persons were stratified by body weight (not overweight or overweight). At baseline, 5.4% of shoppers judged to be not overweight used the stairs. The health benefits sign increased stair use to 7.2% (difference, 1.8 percentage points [CI, 1.2 to 4.7 percentage points]; NNT, 55), and the weight-control sign increased stair use to 6.9% (difference, 1.5 percentage points [CI, 0.3 to 2.6 percentage points]; NNT, 66). The same pattern emerged among persons judged to overweight: The health benefits sign significantly increased stair use from 3.8% to 6.3% [difference, 2.5 percentage points (CI, 1.2 to 3.7 percentage points); NNT, 40], and the weight-control sign increased stair use from 3.8% to 7.7% (difference, 3.9 percentage points [CI, 1.2 to 7.0 percentage points]; NNT, 40). In persons judged not to be overweight, stair use did not differ significantly between the health benefits sign (7.2%) and the weight-control sign (6.9%) (difference

Citrus aurantium and synephrine alkaloids in the treatment of overweight and obesity: an update

Obesity is a major health problem facing the developed and developing world. Efforts by individuals, health professionals, educators, and policy makers to combat the escalating trend of growing obesity prevalence have been multifaceted and mixed in outcome. Various dietary supplements have been marketed to reduce obesity. These products have been suggested to accomplish this by decreasing energy intake and energy absorption, and/or increasing metabolic rate. Ephedra, one such supplement, was banned from sale in the US market because of concerns about adverse events. Another substance, Citrus aurantium, which contains several compounds including synephrine alkaloids, has been suggested as a safe alternative. This review examines the evidence for safety and efficacy of C. aurantium and synephrine alkaloids as examined in animal studies, clinical weight loss trials, acute physiologic studies and case reports. Although at least three reviews of C. aurantium have been published, our review expands upon these by: (i) distinguishing and evaluating the efficacy of C. aurantium and related compounds; (ii) including results from previously unreviewed research; (iii) incorporating recent case reports that serve to highlight, in an anecdotal way, potential adverse events related to the use of C. aurantium and related compounds; and (iv) offering recommendations to guide the design of future trials to evaluate the safety and efficacy of C. aurantium. While some evidence is promising, we conclude that larger and more rigorous clinical trials are necessary to draw adequate conclusions regarding the safety and efficacy of C. aurantium and synephrine alkaloids for promoting weight loss.

Impact of weight loss on Health-Related Quality of Life

To examine the effect of treatment-induced weight loss on Health-Related Quality of Life (HRQL), 38 mildly-to-moderately overweight persons recruited to participate in a study to examine the efficacy of a lifestyle modification treatment program completed a sociodemographic questionnaire, the Beck Depression Inventory (BDI), the Medical Outcomes Study Short-Form Health Survey (SF-36, as an assessment of HRQL), and underwent a series of clinical evaluations prior to treatment. After baseline evaluations, participants were randomly assigned to either a program of lifestyle physical activity or a program of traditional aerobic activity. Participants again completed the SF-36 and BDI after the 13-week treatment program had ended. Weight loss averaged 8.6 ± 2.8 kg over the 13-week study. We found that weight loss was associated with significantly higher scores (enhanced HRQL), relative to baseline, on the physical functioning, role-physical, general health, vitality and mental health domains of the SF-36. The largest improvements were with respect to the vitality, general health perception and role-physical domains. There were no significant differences between the lifestyle and aerobic activity groups on any of the study measures. These data indicate that, at least in the short-term, weight loss appears to profoundly enhance HRQL.

Health-related quality of life among obese persons seeking and not currently seeking treatment

OBJECTIVE To compare sociodemographic characteristics and health-related quality of life (HRQL) between groups of obese persons who sought and did not seek university-based treatment for overweight. METHOD Three-hundred twelve consecutive obese persons sought outpatient university-based weight management treatment. The sample of obese persons (N = 89) who indicated that they were not currently trying to lose weight was derived from a larger convenience sample (N = 232) of persons surveyed in a hospital setting. Both groups completed sociodemographic and brief medical history questionnaires and the HRQL as measured by the Medical Outcomes Study Short-Form-36 Health Survey (SF-36). RESULTS Obese persons who had sought treatment tended to be heavier, older, Caucasian, married, in white collar employment, and reported a higher prevalence of diabetes, hypertension, and pain. In multivariate analyses, both adjusted and unadjusted for these differences, obese persons who had sought treatment were significantly more impaired on the bodily pain, general health, and vitality HRQL domains than those who were not trying to lose weight. DISCUSSION Although differences on sociodemographic and medical variables between the two groups may attenuate the obesity-HRQL relationship somewhat, obesity appears to have a pronounced impact on important dimensions of HRQL independent of whether or not the person is attempting to lose weight

A novel soy-based meal replacement formula for weight loss among obese individuals: a randomized controlled clinical trial.

Objective: To assess the efficacy and safety of a low calorie soy-based meal replacement program for the treatment of obesity.Design: A 12-week prospective randomized controlled clinical trial.Setting: Outpatient weight control research unit.Subjects: One hundred obese (28<BMI≤41 kg/m2) volunteers between the ages of 35 and 65 y. Seventy-four participants completed the trial.Interventions: Participants were randomized to either the meal replacement treatment group (n=50; 240 g/day, 1200 kcal/day) or control group (n=50). Both groups at baseline received a single dietary counseling session and a pamphlet describing weight loss practices.Main outcome measures: Weight, body fat, serum lipid concentrations.Results: By intent-to-treat analysis, the treatment group lost significantly more weight than the control group (7.00 vs 2.90 kg; P<0.001) and had a greater change in total (22.5 vs 6.8 mg/dl; P=0.013) and LDL cholesterol (21.2 vs 7.1 mg/dl; P<0.009). Among completers only, the treatment group again lost more weight (7.1 kg; n=37 vs 2.9 kg; n=37; P=0.0001) and had a greater reduction in total cholesterol (26.1 mg/dl; n=37 vs 6.7 mg/dl; P=0.0012) and a greater change in LDL cholesterol (21.6 vs 5.5 mg/dl; P=0.0025). (For any given degree of weight loss, the reduction in LDL cholesterol was significantly greater in the treatment group.) Treatment was well tolerated and no serious side effects were detected.Conclusions: Use of this soy-based meal replacement formula was effective in lowering body weight, fat mass and in reducing LDL cholesterol beyond what could be expected given the weight lost.Sponsorship: This research was funded by Nutripharma. Dr Allison is a member of the United Soybean Boards Scientific Advisory Panel and Chair of the Research Grants Committee.