Abstract
BACKGROUND
Lifestyle modification is the most important strategy for control of obesity and overweight. Obestatin and adiponectin are the biomarkers of obesity. Thus, this study was performed to examine the effect of educational and encouragement interventions and lifestyle modifications on obesity anthropometric as well as obestatin and adiponectin levels.
METHODS
This semi-experimental study was conducted on a subsample of TABASSOM study. Participants were 41 overweight and obese children and adolescents aged 6-18 years old and 45 overweight and obese adults aged 19-65 years old. Anthropometric characteristics including height, weight, waist and hip circumferences, and body fat percentage (BFP) were measured at the first and after one year at the end of study. We implemented some educational and encouragement interventions regarding dietary modification and physical activity during the study. Obestatin and adiponectin levels were measured at the first and end of study by enzyme-linked immunosorbent assay (ELISA) method.
RESULTS
The study did not show significant effect on anthropometric characteristics such as body mass index (BMI) and waist circumference (WC). BFP decreased significantly in boys, total children and adolescent group, and waist-to-hip ratio (WHR) decreased significantly only in adolescent boys after 1 year (P < 0.050).
CONCLUSION
Educational and encouraging interventions and lifestyle modifications could lead to decrease of body WHR and BFP in adolescent boys. This is helpful in controlling the increasing rate of obesity.
Keywords: Obesity, Overweight, Adults, Children, Adolescents, Obestatin, Adiponectin
Introduction
Obesity is a major cause of non-communicable diseases (NCDs). Studies have shown that weight gain contributes to the incidence of several different diseases, including hypertension (HTN), diabetes, cardiovascular diseases (CVDs), and cancer.1,2 In Iran, the prevalence of overweight and obesity is 50.5% in men, 60.4% in women, 18.6% in boys, and 21.4% in girls.3,4 The World Health Organization (WHO) is seeking through its plans to stop the increasing trend of obesity and overweight in the world by 2025.5
Prevention and treatment are mainly focused on lifestyle modification, including the modification of nutrition and increasing physical exercise.5 Making changes in the living environment and developing guidelines for a healthy lifestyle are major strategies for the treatment of obesity and overweight.6
Regaining weight and behavioral change after interventions also comprise a major challenge in the treatment of obesity. Methods need to be devised that help control weight for a longer time and permanently, if possible.
The interventions performed within the Isfahan Healthy Heart Program (IHHP), which is a community-based interventional program conducted in Isfahan, Iran,7,8 were found to have helped modify certain lifestyle-related factors to an extent.9,10
Various biological and psychological factors contribute to gaining back weight after weight loss.11 Evidence suggests that some treatments for obesity fail in the long term due to the compensatory decrease in metabolism and thus lead to further weight gain.12 The hormones affecting hunger and satiety play an influential role in this phenomenon.13 Obestatin is a gastric hormone that affects the stimulation of appetite and thereby energy balances in the body.14 This hormone stimulates the appetite, regulates weight, and opposes ghrelin.15 Adiponectin, which is secreted from fat tissues, also affects blood glucose regulation and fatty acid catabolism, such that it improves the body’s response to insulin by increasing metabolism.16 In a study to determine the relationship between obestatin and serum insulin levels, body mass index (BMI), waist circumference (WC), and obesity ratios were significantly higher in obese children, while the obestatin level was significantly lower in these subjects.17
Different methods of weight loss are effective in the treatment of obesity, including diet, physical exercise, and surgery, and studies have demonstrated the separate effects of these methods on ghrelin, leptin, adiponectin, resistin, and insulin both in adults and children.18 Few studies have examined that how training individuals to choose their preferred method of weight loss affects their weight goals and what long-term consequences ensue these interventions.19,20 This study seeks to answer the question of whether or not giving training to individuals about the different methods of weight loss and allowing them to freely choose their preferred method help modify these biomarkers and whether the changes in these biomarkers correlate with long-term weight loss or further weight gain. This study was conducted to examine the effect of educational and encouragement interventions on obesity indicators and biomarkers including adiponectin and obestatin levels in overweight and obese subjects.
Materials and Methods
This quasi-experimental study was conducted on February 2012 until March 2013 with a before-after design on a subgroup of people who had participated in the TABASSOM study. In TABASSOM study, overweight and obese volunteers willing to participate in the “lose weight and win” competition were invited through a public announcement through the Islamic Republic of Iran Broadcasting (IRIB) and in the schools.11 The participants included 86 persons that were divided into two groups: 41 children and adolescents (aged 6-18 years) and 45 adults (aged 19-65 years). The inclusion criteria consisted of residing in Isfahan City and having a BMI of 25 or higher for the adults and 85th percentile or higher for the children and adolescents.21 Participants should have no systemic illness, liver and renal disease, and endocrine and mental disorders. Those who did not practice other methods of weight loss, including pharmacotherapy and surgery, were also allocated. We excluded non-compliant subjects from the study. Only 4 children were excluded due to unwillingness to continue. The study was approved by the Ethics Committee of Isfahan Cardiovascular Research Institute (ICRI). Written informed consents were obtained from all participants. Trained health professionals carried out detailed interviews at study baseline to obtain information about participants’ socioeconomic and demographic characteristics.22
In order to implement a comprehensive interventional program, educational and encouraging interventions were applied in the course of one year.
Educational interventions: Educational materials (e.g., pamphlets, CDs, and multimedia programs) were used to explain weight control strategies and inappropriate weight loss methods (e.g., particular medical treatments and their side effects). The participants were also provided with a pamphlet about healthy diet, a CD about physical activity, and follow-up cards. They were asked to keep the cards during the follow-up sessions (6 and 12 months later). Furthermore, after coordination with the Culture Department of Isfahan Municipality, extensive community-based interventions regarding obesity and obesity prevention were provided in 17 cultural centers. Five educational pamphlets were also distributed in schools of Isfahan with the help of Isfahan Municipality’s Committee for Citizenship Culture. Several educational posters were also prepared and installed on billboards in crowded areas of the city.
Encouraging interventions:After six months, the participants with at least 10% weight loss were included in a competition. They were reevaluated after another six months. Twenty individuals who showed weight loss or no weight gain after the second period were randomly rewarded. The anthropometric indices, obestatin and adiponectin levels, were re-evaluated after one year.
Participants’ weight and height were measured with no shoes on and in light clothing using a seca scale with a precision of 0.5 kg and a plastic meter with a precision of 0.5 cm. The BMI was calculated using the equation ‘weight in kilograms divided by the square of the height in meters’. The waist and hip circumferences were measured over light clothing at a standing position using a plastic meter, and the WC was measured at the center of the lower rib and the top of the hip, and the hip circumference at the femur.21 The waist-to-hip ratio (WHR) was also calculated. The body fat percentage (BFP) was measured with a body composition analyzer (Ironman InnerScan Body Composition Monitor from Tanita).
Participants’ adiponectin and obestatin levels were measured using the enzyme-linked immunosorbent assay (ELISA) method and with a buffer kit and an Eastbiopharm elisa kit (Hangzhou Eastbiopharm Co., USA) at baseline and at the end of the project, i.e., one year later.23
All the information collected from the questionnaires and the initial demographic information obtained from the candidates were entered into a computer using Epi Info software. Once thoroughly analyzed and managed, the data were reported as mean and standard deviation (SD), and the non-normally distributed data were reported as median and interquartile range, and all this data were then tabulated.
The paired sample t-test was used to compare the data before and after the intervention, and Wilcoxon’s nonparametric test (the Wilcoxon signed-rank test) was used to compare the non-normally distributed data. The independent sample t-test was used to examine the percentage of changes between the two genders, and Mann-Whitney’s nonparametric U test was used for the non-normally distributed data. Data were analyzed in SPSS software (version 15, SPSS Inc., Chicago, IL, USA). The level of statistical significance was set at P < 0.050.
Results
Table 1 indicates the mean demographic and anthropometric data of adults and children and adolescents based on gender. The mean weight, BMI, WHR, and BFP differed significantly between the two genders in adults and WHR in children and adolescents (P < 0.050).
Table 1.
Basic characteristics of study participants
| Characteristics | Adults |
Children and adolescents |
||||||
|---|---|---|---|---|---|---|---|---|
| Women | Men | P | Total | Girls | Boys | P | Total | |
| Number | 22 | 23 | 45 | 18 | 23 | 41 | ||
| Mean ± SD | Mean ± SD | Mean ± SD | Mean ± SD | Mean ± SD | Mean ± SD | |||
| Age (year) | 40.60 ± 9.80 | 45.20 ± 10.80 | 0.160 | 43.05 ± 10.50 | 12.50 ± 3.30 | 12.60 ± 2.90 | 0.870 | 12.56 ± 3.06 |
| Weight (kg) | 79.10 ± 11.80 | 86.60 ± 9.50 | 0.030 | 82.90 ± 11.20 | 60.81 ± 16.52 | 64.29 ± 20.02 | 0.550 | 62.76 ± 18.43 |
| BMI (kg/m2) | 31.63 ± 4.30 | 28.84 ± 2.46 | 0.010 | 30.20 ± 3.72 | 26.30 ± 4.24 | 26.89 ± 4.59 | 0.670 | 26.63 ± 4.40 |
| WC (cm) | 96.07 ± 9.78 | 99.60 ± 15.00 | 0.140 | 97.88 ± 7.83 | 81.28 ± 8.71 | 86.96 ± 11.52 | 0.090 | 84.46 ± 10.65 |
| WHR | 0.89 ± 0.08 | 0.95 ± 0.04 | 0.001 | 0.92 ± 0.07 | 0.84 ± 0.06 | 0.91 ± 0.04 | < 0.001 | 0.88 ± 0.06 |
| BFP | 35.95 ± 5.14 | 26.40 ± 4.23 | < 0.001 | 31.07 ± 6.70 | 34.95 ± 4.56 | 30.34 ± 7.83 | 0.050 | 32.20 ± 6.86 |
BMI: Body mass index; WC: Waist circumference; WHR: Waist-to-hip ratio; BFP: Body fat percentage; SD: Standard deviation
Comparison of the median obestatin level before and after the intervention in the adults and children and adolescents by gender has been shown in table 2. Although the obestatin level increased among the women and decreased among the men, the difference observed was not statistically significant (P > 0.050). There was no significant obestatin reduction in children and adolescents (P > 0.050).
Table 2.
Comparing the median of obestatin level before and after the intervention in two groups of adults and children and adolescents based on sex
| Obestatin (ng/ml) | Before intervention | After intervention | P |
|---|---|---|---|
| Median (25th-75th) | Median (25th-75th) | ||
| Adults | |||
| Women | 6.03 (5.24-6.20) | 6.12 (5.43-6.86) | 0.350 |
| Men | 5.58 (4.76-6.44) | 5.43 (5.01-5.88) | 0.130 |
| Total | 5.93 (5.03-6.24) | 5.76 (5.11-6.62) | 0.200 |
| Children and adolescents | |||
| Girls | 0.91 (0.75-1.08) | 0.93 (0.80-1.00) | 0.570 |
| Boys | 3.77 (2.51-8.29) | 3.85 (3.08-6.20) | 0.320 |
| Total | 2.13 (0.94-4.08) | 2.86 (2.67-4.52) | 0.130 |
The level of adiponectin had a non-significant change in adults and children and adolescents (P > 0.050) (Table 3).
Table 3.
Comparing the mean of adiponectin level before and after the intervention in two groups of adults and children and adolescents based on sex
| Adiponectin (ng/ml) | Before intervention |
After intervention |
P |
|---|---|---|---|
| Mean ± SD | Mean ± SD | ||
| Adults | |||
| Women | 33.10 ± 19.65 | 31.62 ± 18.11 | 0.340 |
| Men | 29.73 ± 21.60 | 26.23 ± 19.28 | 0.280 |
| Total | 31.40 ± 20.50 | 28.88 ± 18.86 | 0.240 |
| Children and adolescents | |||
| Girls | 24.65 ± 12.81 | 22.22 ± 11.52 | 0.310 |
| Boys | 25.85 ± 13.92 | 29.73 ± 14.39 | 0.240 |
| Total | 25.32 ± 13.30 | 25.85 ± 13.11 | 0.760 |
SD: Standard deviation
Table 4 shows the mean of BMI, WC, WHR, and BFP before and after the intervention in adults and children and adolescents by gender. A significant difference was shown between mean of WHR and BFP in boys (P = 0.040 and P = 0.008, respectively) and BFP in total children and adolescents (P = 0.006), but no significant difference was observed in adults. The other indices did not show significant differences before and after the intervention in either of the age groups (P > 0.050).
Table 4.
Comparing the mean anthropometric characteristics before and after the intervention in two groups of adults and children and adolescents based on sex
| Variable | Before intervention |
After intervention |
P |
|---|---|---|---|
| Mean ± SD | Mean ± SD | ||
| Adults | |||
| BMI (kg/m2) | |||
| Women | 31.63 ± 4.30 | 31.43 ± 3.69 | 0.410 |
| Men | 28.84 ± 2.46 | 28.43 ± 3.29 | 0.330 |
| Total | 30.20 ± 3.72 | 29.95 ± 3.71 | 0.180 |
| WC (cm) | |||
| Women | 96.07 ± 9.78 | 96.09 ± 8.97 | 0.820 |
| Men | 99.61 ± 5.00 | 99.49 ± 8.60 | 0.630 |
| Total | 97.88 ± 7.83 | 97.75 ± 3.71 | 0.520 |
| WHR | |||
| Women | 0.89 ± 0.08 | 0.88 ± 0.08 | 0.730 |
| Men | 0.95 ± 0.04 | 0.96 ± 0.04 | 0.710 |
| Total | 0.92 ± 0.07 | 0.92 ± 0.07 | 0.600 |
| BFP | |||
| Women | 35.95 ± 5.14 | 35.77 ± 4.74 | 0.580 |
| Men | 26.40 ± 4.23 | 26.68 ± 7.84 | 0.500 |
| Total | 31.07 ± 6.70 | 31.06 ± 8.54 | 0.840 |
| Children and adolescent | |||
| BMI (kg/m2) | |||
| Girls | 26.30 ± 4.24 | 26.21 ± 3.90 | 0.740 |
| Boys | 26.89 ± 4.59 | 26.74 ± 5.03 | 0.620 |
| Total | 26.63 ± 4.40 | 26.55 ± 4.56 | 0.540 |
| WC (cm) | |||
| Girls | 81.28 ± 8.71 | 81.16 ± 8.71 | 0.580 |
| Boys | 86.96 ± 11.52 | 86.43 ± 14.7 | 0.310 |
| Total | 84.46 ± 10.65 | 84.38 ± 12.60 | 0.380 |
| WHR | |||
| Girls | 0.84 ± 0.06 | 0.85 ± 0.06 | 0.530 |
| Boys | 0.91 ± 0.04 | 0.89 ± 0.06 | 0.040 |
| Total | 0.88 ± 0.06 | 0.87 ± 0.06 | 0.210 |
| BFP | |||
| Girls | 34.59 ± 4.56 | 33.83 ± 4.99 | 0.330 |
| Boys | 30.34 ± 7.83 | 26.87 ± 9.07 | 0.008 |
| Total | 32.20 ± 6.16 | 29.93 ± 8.25 | 0.006 |
BMI: Body mass index; WC: Waist circumference; WHR: Waist-to-hip ratio; BFP: Body fat percentage; SD: Standard deviation
Discussion
The results showed that the education and encouragement interventions did not have a significant effect on anthropometric factors in either of the age groups; however, they did lead to a significant reduction in the WHR and BFP in the boy participants; furthermore, no changes were observed in adiponectin and obestatin levels in either age group.
It has been suggested that adiponectin, which is a peptide derived from fat tissues, is inversely correlated with obesity;24,25 so that the reduced changes in serum adiponectin largely contribute to obesity-related complications and problems.26,27 Studies also show that when adiponectin decreases, the body reserves fat in risky regions, such as the muscular tissues, and the fat percentage then increases in these regions.28 However, no significant reductions were observed in anthropometric indicators in this study, and adiponectin also did not change significantly.
Evidence suggests that when the adiponectin level is high, the body protects itself from the shortage of energy through reserving fat in the fat cells. This fat tissue is first added to the layer beneath the skin, and when adiponectin decreases, the body continues to reserve more fat in certain critical regions, which can lead to inflammation and increased risk of heart disease.29,30
Few studies have examined the obestatin peptide and produced contradictory results about plasma obestatin level. A study conducted in 2008 on overweight children and adolescents showed a significantly higher plasma obestatin level in the overweight group compared to the study group with normal weight. That study found that weight loss increased obestatin in the overweight group.19 Ghanbari-Niaki et al. reported similar findings, only with this difference that the level of obestatin increased significantly after weight loss in their study; while, before their weight loss, the overweight children had lower levels of obestatin compared to the group of children with normal weight.31
The present study found that obestatin levels did not change significantly in the adults or children and adolescents; however, the WHR and BFP changed significantly in the boy participants. Obesity and overweight were found to decrease the obestatin level.32 In a study by Beasley et al., overweight and obese people had lower levels of obestatin compared to people with normal weight.32
In the study by Lippl et al., no significant differences were observed in the obestatin level between the overweight and the thin children; however, the level of obestatin increased significantly in the group of overweight children after their weight loss with diet, but the change was not significant in overweight children who did not lose much weight.33 Overall, obestatin appears to inhibit overeating and is associated with proven appetite-suppressing effects and thus, plays a key role in weight control.33 Obestatin and adiponectin can be used as markers of the success of interventions and also to monitor treatments.34 Obesity is an independent risk factor in adulthood that is closely related to health factors.35,36 Interventions are necessary for the control, reduction, or at least stabilization of obesity. The results of this study revealed that instructional and incentive interventions cannot reduce overweight and obesity, but can prevent weight gain and control its progressive trend, especially in children and adolescents, who are a more sensitive age group, since the modification of their weight ultimately leads to lower rates of obesity in the society. In a study conducted by Sahota et al. in the United Kingdom for examining the effects of an intervention program on the obesity, the subjects’ BMI did not change significantly after the intervention (which is in line with the present findings), but some of their dietary habits were slightly modified.37 Studies show that exercise can probably affect obestatin levels.38 The intervention performed in this study targeted increased physical activity and improved diets through educational materials, CDs, and offering prizes; however, the results showed that even these strategies could not really increase the frequency of physical activity.
Conclusion
The interventions performed did not significantly affect the anthropometric factors in either age group examined in the study; however, they did lead to a significant reduction in the WHR and BFP in boy participants. Moreover, these interventions did not significantly affect serum adiponectin and obestatin levels. Although the instructional and incentive interventions given did not significantly reduce obesity, they are still regarded as helpful due to their inhibitory effect on the increasing trend of obesity. Further long-term comprehensive interventions performed with better facilities are suggested for achieving a maintenance lifestyle modification to decrease obesity indices and increase adiponectin and obestatin levels.
Acknowledgments
Here it is necessary to thank the management of the development of research, evaluation of research, and coordination of research centers that approved the implementation of research project (number 191124) in Isfahan University of Medical Sciences.
Footnotes
Conflicts of Interest
Authors have no conflict of interests.
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