This document discusses obesity and its management through diet and exercise. It provides definitions of obesity based on BMI and waist circumference. Obesity is a risk factor for many health conditions. Dietary intervention is key to weight loss, including low-calorie, low-fat, low-carbohydrate diets, and very low-calorie diets. Exercise alone does not lead to significant weight loss but helps maintain weight lost through diet. Combining calorie restriction and exercise can result in 5-9% weight loss over 6 months.

1. Tharwat's Family
Tharwat's Family
O B E S I T Y A N D T H E D I G E S T I V E S Y S T E M
Diet and exercise in management of obesity and overweight
Kwong Ming Fock* and Joan Khoo†
Departments of *Gastroenterology and †Endocrinology, Changi
General Hospital, Singapore
Keywords
BMI, diet, exercise, NAFLD, obesity.
Accepted for publication 30 September 2013.
Correspondence

2. Professor Kwong Ming Fock, Division of
Gastroenterology, Department of Medicine,
Changi General Hospital, 2 Simei Street 3,
Singapore 529889. Email:
[email protected]
Abstract
According to World Health Organization, in 2010 there were
over 1 billion overweight
adults worldwide with 400 million adults who were obese.
Obesity is a major risk factor for
diabetes, cardiovascular disease, musculoskeletal disorders,
obstructive sleep apnea, and
cancers (prostate, colorectal, endometrial, and breast). Obese
people may present to the
gastroenterologists with gastroesophageal reflux, non-alcoholic
fatty liver, and gallstones.
It is important, therefore, to recognize and treat obesity.
The main cause of obesity is an imbalance between calories
consumed and calories
expended, although in a small number of cases, genetics and
diseases such as hypothy-
roidism, Cushing’s disease, depression, and use of medications
such as antidepressants and
anticonvulsants are responsible for fat accumulation in the
body.
The main treatment for obesity is dieting, augmented by
physical exercise and supported
by cognitive behavioral therapy. Calorie-restriction strategies
are one of the most common
dietary plans. Low-calorie diet refers to a diet with a total
dietary calorie intake of
800–1500, while very low-calorie diet has less than 800 calories
daily. These dietary
regimes need to be balanced in macronutrients, vitamins, and
minerals. Fifty-five percent

3. of the dietary calories should come from carbohydrates, 10%
from proteins, and 30% from
fats, of which 10% of total fat consist of saturated fats. After
reaching the desired body
weight, the amount of dietary calories consumed can be
increased gradually to maintain a
balance between calories consumed and calories expended.
Regular physical exercise
enhances the efficiency of diet through increase in the satiating
efficiency of a fixed meal,
and is useful for maintaining diet-induced weight loss. A meta-
analysis by Franz found that
by calorie restriction and exercise, weight loss of 5–8.5 kg was
observed 6 months after
intervention. After 48 months, a mean of 3–6 kg was
maintained.
In conclusion, there is evidence that obesity is preventable and
treatable. Dieting and
physical exercise can produce weight loss that can be
maintained.
Introduction
Since 1980, obesity has more than doubled globally and is now
considered as a major health hazard and a global epidemic. This
review aims to evaluate the current management of obesity and
overweight employing a combination of dietary interventions,
exercise, and behavioral modification. For some patients,
pharma-
cological therapy or bariatric surgery is required.
Definition of obesity
Obesity can be defined as an excessive amount of fat that
increases
the risk of medical illness and premature death. A simple and
convenient way of defining obesity and overweight led by the
World Health Organization (WHO) and the National Institute of

4. Health (NIH) is based on body mass index (BMI).
BMI is derived by dividing one’s weight in kilograms by the
square of one’s height in meters. Classification of overweight
and
obesity is based on data gathered from population-based
epidemi-
ology studies that evaluated the relationship between obesity
and
rates of mortality and morbidity that are adiposity related. A
BMI
(kg/m2) between 25 and 29.9 is deemed to be overweight.
Obesity
is defined as BMI ≥ 30 and is further subdivided into Class I–
III.
There is some evidence to suggest that risks of adiposity-related
complications occur at lower BMIs in Asians. Hence, China1
used
a BMI of 28 for obesity and Japan2 used a BMI cut-off of 25
kg/m2
for cut-off. The WHO has recommended that BMI > 27.5 kg/m2
be used as a cutoff for Asians, taking into consideration the
increased cardiovascular risk at the BMI.
Health consequences of obesity
Mortality. On average, obesity reduces life expectancy by 6 to
7 years:3 a BMI of 30–35 reduces life expectancy by 2–4 years
while severe obesity (BMI > 40) reduces life expectancy by
10 years.4
doi:10.1111/jgh.12407
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5. 59Journal of Gastroenterology and Hepatology 2013; 28 (Suppl.
4): 59–63
© 2013 Journal of Gastroenterology and Hepatology Foundation
and Wiley Publishing Asia Pty Ltd
mailto:[email protected]
Morbidity. Complications of obesity are either directly caused
by obesity or indirectly related through mechanisms sharing a
common cause such as a sedentary life style or poor diet. The
strongest link is with type 2 diabetics. Obesity accounts for 64%
of
cases of diabetics in men and 79% of cases in women. Other
diseases attributable to obesity are cardiovascular disease—
hypertension, stroke, coronary artery disease, venous stasis
deep
vein thrombosis, osteoarthritis, gastrointestinal disease, gastro-
esophageal reflux disease, cholelithiasis, non-alcoholic fatty
liver
disease (NAFLD), endometrial breast cancer, and colorectal
cancer. Obesity is the leading cause of cancer just behind
smoking.
Metabolic disorders include metabolic syndrome, prediabetic
state, hyperlipidemia, and polycystic ovary syndrome. Most
patients with obstructive sleep apnea (OSA) are obese, although
in
lean persons, other factors such as cephalometric defects
contrib-
uted to risk of OSA. In addition to BMI and waist
circumference,
it is important to look out for comorbidities that are associated
with obesity such as diabetes, NAFLD, polycystic ovary syn-
drome, OSA, and osteoarthritis.

6. Clinical evaluation of obesity in adults:
waist circumference
Central or truncal obesity, as measured by waist circumference,
is
also associated with increased risk for heart disease, diabetes
mel-
litus, hypertension, and hyperlipidemia.5
The WHO STEPwise approach to surveillance protocol for
measuring waist circumference requires waist circumference to
be
measured at the midpoint between the lower margin of the pal-
pable rib and the top of the iliac crest.6 The NIH, which
provided
the protocol for use in the National Health and National Exami-
nation Survey, determines that waist circumference be measured
at the top of the iliac crest. Ethnic differences exist, and in
Asia,
waist circumference > 80 cm for females and > 90 cm for men
are
considered outside the normal range.7
Establishing the cause of overweight
and obesity
Although excessive food energy intake and a sedentary lifestyle
account for most cases of overweight and obesity, it is
important
to recognize that medical illness and drug treatment of medical
illness can increase the risk of obesity and are amenable to
treatment. The neuroendocrine causes of obesity include
hypothy-
roidism, Cushing’s syndrome, growth hormone deficiency,
hypo-
gonadism, and polycystic ovary syndrome. Eating disorders,
notably binge eating disorders and night eating syndrome, also

7. give rise to obesity.
Obesity is not regarded as a psychiatric disorder, but the
risk of obesity is increased in patients with psychiatric
disorders
such as depression. Medications that can cause weight gain
include antidepressants, antidiabetic drugs, anticonvulsants,
anti-
psychotic medication, beta-blockers, and steroid hormones.
Cessation of smoking is associated with weight gain. It is
important to note comorbidities associated with obesity: dia-
betes mellitus, hyperlipidemia, hypertension, and cardiovascular
disease.
Medical treatment of overweight and
obesity
The management of overweight and obesity is lifestyle interven-
tion, consisting of dietary intervention, exercise, and behavioral
treatment.
Setting a goal for weight loss
Setting a goal for weight loss is the first step in planning a
weight
loss program. The patient needs to accept that the goal is
reason-
able, realistic, and attainable. An initial weight loss of 5–7% of
bodyweight within 6 months is achievable. The Diabetes
Preven-
tion Program is an example of a successful lifestyle intervention
program that set the weight loss target of 7% of bodyweight.8
Dietary intervention
Dietary intervention is the cornerstone of weight loss therapy.
Most of the dietary regimens proposed for weight loss focus on
energy content and macronutrient composition. It is the energy
content that determines the efficiency of the dietary regimens.

8. Obesity treatment guidelines issued by the NIH recommend that
persons who are overweight or who have class I obesity and
who
have two or more risk factors should reduce their energy intake
by
500 kcal/day.9 Persons with class II and class III obesity should
strive for 500–1000 kcal/day reduction. With a reduction of
500 kcal/day energy intake, a weight reduction of 0.5 kg/week
can
be achieved.
To provide a diet that results in the desired energy deficit, it is
necessary to determine the patient’s daily energy requirement,
which can be estimated by using the Harris–Benedict
equation10 or
the WHO equation11 or American Gastroenterological
Association
dietary guidelines.12
Type of diets
In general, there are four types of dietary regimens used in the
treatment of the overweight or obese persons: (Table 1)
1 Low-calorie diet (LCD)
2 Low-fat diet
3 Low-carbohydrate diet
4 Very low-calorie diet (VLCD)
The first three diets are 800–1500 kcal/day while VLCD is
< 800 kcal/day.
LCD. LCDs are high in carbohydrate (55–60%), low in fat (less
than 30% of energy intake), and high in fiber and have a low-
glycemic index. Alcohol and energy-dense snacks should be
avoided. LCD has been shown in 34 randomized trials to reduce
body weight by 8% during 3–12-month period.13 Overweight or

9. obese patients tend to underestimate their energy intake. To
help
them overcome this, portion-controlled or prepackaged meals
that
make up the required energy intake are available. Replacement
meals are available as drinks, nutrition bars, or prepackaged
meals.
A 4-year study demonstrated weight loss improvement in blood
sugar and blood pressure for persons taking meal replacement
diets.14
Diet and exercise for weight management KM Fock and J Khoo
60 Journal of Gastroenterology and Hepatology 2013; 28
(Suppl. 4): 59–63
© 2013 Journal of Gastroenterology and Hepatology Foundation
and Wiley Publishing Asia Pty Ltd
Low-fat diets. These diets reduce the daily intake of fat to
20–25% of total energy intake. For a person on a 1500-calorie
diet,
this translates to 30–37 g of fat, which can be counted using
food
label from packages. Alternatively, a dietician can provide the
person with a specific menu plan that has reduced fat.
According to a meta-analysis of 16 trials, low-fat diet used over
2–12 months resulted in mean weight loss of 3.2 kg and
improved
cardiovascular risk factors (Table 1).15
Low-carbohydrate diet. The carbohydrate content of the
diet is an important determinant of short-term (less than 2

10. weeks)
weight loss. Low-carbohydrate (60–150 g of carbohydrate/day)
and very low-carbohydrate diet (0 to < 60 g) have been popular
for
many years. Glycogen utilization occurs when carbohydrate
intake
is restricted. When the carbohydrate intake is less than 50
g/day,
ketosis will develop from glycogenolysis, resulting in fluid loss.
Many of the current low-carbohydrate diets (e.g. Atkins diet)
limit
carbohydrate intake to 20 g/day but allow unrestricted amounts
of
fat and protein. A meta-analysis of five trials found that weight
loss
at 6 months favoring low-carbohydrate over low-fat diet is not
sustained at 12 months.16 Triglycerides and high-density
lipopro-
tein (HDL) cholesterol changed more favorably in people
assigned
to low-fat diet. There are data from the National Health Study
and
Health Professional, Follow Up study that low-carbohydrate diet
with the highest decile for animal protein and fat were
associated
with higher all-cause and cardiovascular mortality.17
VLCD. VLCDs are diets with energy content of 200–800 kcal/
day. Diets below 200 kcal/day are starvation diets. VLCDs are
not
recommended for general use, as there are significant adverse
events such as electrolyte unbalance, low blood pressure, and
increased risk of gallstones. Its use needs to be supervised by
trained medical personnel.
Each of the four types of diet for weight loss has its proponents.

11. In a meta-analysis of 80 weight loss studies, mean weight loss
of
5 to 8.5 kg (5–9%) was observed during the first 6 months from
interventions involving a reduced-energy diet and/or weight loss
medications with weight plateaus at approximately 6 months,
with
maintenance of 3 to 6 kg (3–6%) of weight loss at 48 months.18
A
randomized controlled trial comparing four weight loss diets
with
different compositions of fat, carbohydrate and protein found no
difference in outcomes, with a 2- to 4-kg weight loss with all
diets
after a year.19 After 2 years, all calorie-restricted diets result in
equal weight loss irrespective of the macronutrient
composition.19
In contrast, all studies found that dietary adherence is an
important
determinant of weight loss.13–19 Thus, choosing a diet with a
mac-
ronutrient composition based on a subject’s taste preference can
achieve better compliance.
Exercise and obesity
Physical activity alone is not an effective method for achieving
initial weight loss, although most overweight or obese people
tend
to choose exercise as the first interventional option. Without
calorie restriction, weight loss through exercise alone is quite
small, about 0.1 kg/week.20 A meta-analysis showed that
exercise
alone did not result in significant weight loss attempts, although
no
further weight gain was observed after 12 months.18 Although

12. exercise is not effective for initial weight loss, physical activity
is
important for maintaining weight loss achieved through dietary
intervention. Meta-analyses of 493 studies have shown that
people
who diet and exercise maintained their weight loss better than
those who relied on diet alone.21 Before starting an exercise
program, patients should be advised of joint and
musculoskeletal
injuries as well as cardiovascular risks. The risk of exercise
stress
testing before an exercise program is controversial. The
American
College of Cardiology and American Heart Association recom-
mend treadmill for asymptomatic subjects with diabetes
mellitus,
men older than 45 years of age, and women older than 55 years
of
age before embarking on an exercise program.22 Other
organiza-
tions recommend no stress testing for symptomatic subjects
under-
going moderate-intensity exercise with guidance in exercise
intensity. In our hospital, we use a physical exercise readiness
questionnaire for screening purposes.
The American College of Sports Medicine recommended in
2009 that moderate-intensity exercising between 150 and 250
min
weekly is effective in preventing weight gain. To provide and
Table 1 Comparison of different weight-loss diets13–19
Diet Daily caloric content/
composition

13. Mean weight loss Benefits Disadvantages
Low calorie 800–1500 kcal
55–60% carbohydrate
(high fiber, low GI)
< 30% fat
∼ 10% in 3–12 months Reduction in blood glucose,
TG, LDL, BP
Compliance difficult in long term
Low fat 1000–1500 kcal
20–25% fat
∼ 5% in 2–12 months Reduction in blood glucose,
LDL, BP
Less palatable, feel hungry easily
Increase TG
Low carbohydrate 1000–1500 kcal
60–150 g of carbohydrate
< 60 g (very low carbohydrate)
∼ 5% in 2–12 months Faster initial weight loss
than low-fat diets
Reduced blood glucose,
TG, LDL, BP
Ketosis when carbohydrate intake
< 50 g/day
Very low-calorie diet 200–800 kcal

14. 55–60% carbohydrate
(high fiber, low GI)
< 30% fat
> 10% in 2–8 weeks Rapid weight loss Electrolyte imbalance,
hypotension,
gallstones
Needs medical supervision
BP, blood pressure; GI, glycemic index; LDL, serum low-
density lipoprotein cholesterol; TG, serum triglyceride.
KM Fock and J Khoo Diet and exercise for weight management
61Journal of Gastroenterology and Hepatology 2013; 28 (Suppl.
4): 59–63
© 2013 Journal of Gastroenterology and Hepatology Foundation
and Wiley Publishing Asia Pty Ltd
maintain a clinically significant weight loss, at least 200–300
min/
week of moderate-intensity aerobic exercise is required. Resis-
tance training does not enhance weight loss but may increase
fat-free mass. Even in the absence of significant weight loss,
regular aerobic and resistance exercise improves cardiovascular
fitness22 and obesity-related comorbidities such as NAFLD.23
A
supervised exercise program involving personal trainers induces
and maintains weight loss more effectively than unsupervised
physical activity.22 Exercise reduces food intake by increasing
the

15. satiating efficiency of a fixed meal.24
NAFLD
NAFLD patients are usually overweight or obese and have
under-
lying insulin and or leptin resistance leading to dysfunctional
energy metabolism. Weight loss of 10% in overweight NAFLD
patients improves liver biochemistry as well as hepatic steatosis
and necroinflammation. Lifestyle modification consisting of
exer-
cise and diet can help the patients to achieve these goals. A 4–
4.5%
weight loss can result in 50% reduction in serum alanine amino-
transferase, while with exercise alone and no weight loss,
signifi-
cant improvement in aminotransferase levels can occur, but its
effect on liver histology is unknown.23 The American
Association
for the Study of Liver Diseases, the American College of
Gastro-
enterology, and the American Gastroenterology Association rec-
ommend weight loss as the preferred method in management of
NAFLD.25
Bariatric surgery
Bariatric surgery is defined as gastrointestinal surgery to help
severely obese patients lose weight. The US National Institutes
of Health’s 2013 guidelines recommended surgery for adults
with BMI ≥ 40 kg/m2 without comorbidities or 35 kg/m2 with
comorbidities who fail to lose weight by nonsurgical
methods,26
and suggested that patients with BMI of 30–34.9 kg/m2 with
dia-
betes or metabolic syndrome may also be offered a bariatric
pro-

16. cedure, although current evidence is limited by the lack of long-
term data demonstrating net benefit. A recent Asian Consensus
Meeting on Metabolic Surgery27 also recommended that the
BMI
cutoffs be lowered to 35 and 32.5, respectively, and that surgery
be
considered for Asian adults with BMI ≥ 30 kg/m2 and central
obesity (WC > 80 cm in females or > 90 cm in males) and at
least
two features of metabolic syndrome (raised triglycerides, low
HDL cholesterol, hypertension, high-fasting plasma glucose).
Gastric banding is a reversible restrictive procedure, while
laparo-
scopic sleeve gastrectomy, Roux-en-Y gastric bypass, and bilio-
pancreatic diversion combine restrictive and malabsorptive
effects
that produce 15–35% loss of baseline weight and improve other
comorbidities.26
Conclusion
Overweight and obesity are increasing at an alarming rate
globally
and has reached epidemic proportions in almost every country.
Obesity has a significant contribution toward cardiovascular
dis-
eases, metabolic disorders, gastrointestinal disorders, and
cancers.
Yet in early stages of weight gain, when a person is overweight,
its
progression to morbid obesity can be arrested through diet and
exercise, without the need for medication, endoscopic, or
surgical
procedures. We have attempted to put further evidence in
support
of current best practices in dietary management and exercise.

17. Finally, we conclude with two mnemonics that some of our team
members found useful in clinical practice. Factors that
contribute
to obesogenic state are
• Diseases—hypothyroidism, Cushing’s disease
• Drugs—corticosteroids, antidepressants, antipsychotics
• Diet—intake > activity
• Drink—beer, wine, sugar drinks
• Decreased—physical activity
• Depression and psychosocial
An ABCDE approach28 to obesity:
A For measurement of cardiovascular risk and comorbidity
B For blood pressure control
C For cholesterol management
D For diet control and text for diabetes
E For exercise therapy
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KM Fock and J Khoo Diet and exercise for weight management
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ISSN 2304-3415, Russian Open Medical Journal 2012; 1: 0308
1
Preventive medicine
© 2012, LLC Science and Innovations, Saratov, Russia
www.romj.org
Original article
Do different groups have different risk factors for dieting and e
xercise as body management
strategies?
Behshid Garrusi, Mohammad Reza Baneshi, Fatemeh Amiri

24. Kerman University of Medical Sciences, Kerman, Iran
Received 17 October 2012, Revised 27 Oct 2012, Accepted 31
Oct 2012.
© 2012, Garrusi B., Baneshi M.R., Amiri F.
© 2012, Russian Open Medical Journal
Abstract: Aim –
Body change strategies are activities that could be potentially h
armful. Individuals may use different methods for achieving
advertised ideal body. Some of demographic and psychosocial c
ontributing factors could be affect decision regarding body man
agement
activities. In Iran there is a few research about this matter, there
fore the aim of this study was exploring risk factors in body ma
nagement.
Materials and Methods –
In this cross sectional study, 400 people participated that incl
uding general population, university students and
body building clubs attainders. The self administrated questionn
aire based on reliable sources of body image that evaluated its v
alidity
and validity. Statistical analysis was done by using
central indexes and distribution and logistic regression.
Data analysis was done by
software of SPSS 16. Results –
Marital status, education, economic status, age and BMI had no
relation with body management strategies.
Birthplace effects on choose of diet and exercise. Gender is onl
y had effect on exercise choosing. Use of Western TV had effect

25. on doing
exercise. Pressure of relatives was an important factor in
decision about dieting. Self steam and compare of
appearance with others
affected choosing of dieting. There were no differences
between selected groups. Conclusion – In spite of
similarities between body
dissatisfaction and its management strategies with other studies
in Iran, there is necessity for future studies.
Keywords: dieting, exercise, body image, Iran.
Cite as
Garrusi B, Baneshi MR, Amiri F. Do different groups have diffe
rent risk factors for dieting and exercise as body management st
rategies? Russian Open
Medical Journal 2012; 1: 0308.
Correspondence to Behshid Garrusi. Address: Department
of Community Medicine, Afzallipour Medical School,
Kerman University of Medical Sciences,
Kerman, Iran(IR). Tel: +98‐341‐3224613. Fax: +98‐341‐322167
1. E‐mail: [email protected], [email protected]
Introduction
While concerns about one’s body and degree of physical
attractiveness have been a part of history, these concerns
have
become more intense in recent decades. Body image has
been
defined as the perception of overall physic cal appearance
.It
consider a multidimensional issue that includes perception,
attitude, feeling and the effects of these perceptions on
the
individual’s behaviors [1]

26. Body size estimation, attractiveness and one’s feelings about
these are among the aspects of body image [1]. Body image is t
he
mental representation about own body. Body satisfaction and it
s
related problems were, in the past, known as a western
culture
phenomenon; however, recent studies are finding that it is now
a
worldwide matter. Despite previous beliefs, body concerns
and
eating disorders are increasing in Asian countries, and in some
of
these societies, their prevalence is similar to that of
western
cultures [2, 3]. In recent decades, the emphasis for the
ideal
women has been on thinness, while the emphasis for the
ideal
man has been on muscledevelopment/masculinity [4]. These bod
y
characteristics are considered symbols of success, self control a
nd
sexual attractiveness in women and empowerment in men [1, 4].
There are multiple differences between Asian cultures that can
affect an individual’s perceptions, attitudes and behaviors [5]. F
or
example,
in east Asia, Japanese women suffer more from eating
disorders and body dissatisfaction than Taiwanese women
[6].
Researchers contend that there are many cultural

27. differences
within east Asian countries [7] as well as significant
differences
between eastern and western Asian cultures.
Body image and body satisfaction can be affected by
many
socio‐cultural factors [8, 9]. Culture plays a significant role
in the
conceptualization of beauty and attractiveness [8]. Desire
for
achieving of Ideal body, could be cause some of health
consequences ,such as eating disorders and unhealthy behaviors
for body change. Body dissatisfaction is correlated with
various
attempts to change one’s body, and these efforts can
begin in
children as young as 5‐years‐old [10, 11]. The most
accepted
method is dieting, a method that can result inanorexia, if
successful and encouraged by others,orbulimia, which
hascompensatory activities such as
induced vomiting and theuse
of laxatives [12]. As previously stated, females wish to be thinn
er,
and males wish to be more masculine [10]. These desires
can
cause males to exercise excessively and engage in steroid
use,whilefemalesprefer dieting strategies or surgery. In
somestudies,however,body image dissatisfaction negatively
correlated with physical activity, especially among adolescent g
irls
[10]. The aim of this identifying of body change strategies tha
t
were chosen by different groups in one Iranian sample.

28. [
Tharwat's Family
Tharwat's Family
ISSN 2304-3415, Russian Open Medical Journal 2012; 1: 0308
2
Preventive medicine
© 2012, LLC Science and Innovations, Saratov, Russia
www.romj.org
Material and Methods
This population‐based study was carried out in Kerman,
the
capital of the largest province in Iran. The main outcomes of the
study include body change strategies. We focused on two
main
methods: diet (restricted food, induced vomiting) and
exercise
(heavy exercise for masculinity or weight reduction). In this stu
dy,
was done in three different group, general population, universit
y
students and body building (gym) users. These participants were

29. selected) by multistage sampling.
Self‐administrated questionnaire include below parts:
Demographic variables: Age (>20, <20 years), gender
(male,
female), economical status (fair to medium and good to excellen
t),
marital status (married, single), place of birth (big cities,
small
cities and village), BMI (cut‐offs at 18.5, 24.9, and 29.9, subjec
ts
were categorised into four groups: BMI<18.5 (thin), BMI=18.5‐
24.9
(normal), BMI=25‐29.9 (overweight), BMI>30 (obese), use
of
media (TV, fashion magazine).
Socio‐cultural variables: This parts evaluated comparison
of
body with others {Physical Appearance Comparison Scale (PAC
S)},
that had acceptable reliability and validity in Persian
[13],
perceived pressure from relatives {Perceived Socio‐cultural
Pressure Scale (PSPS)}, Body Satisfaction (Figure Rating Scale
) that
subjects were classified into three groups: no body dissatisfacti
on
their current and ideal shapes were the same), mild dissatisfacti
on
(BD score of 1), and severe dissatisfaction (the difference
was
greater than 1), and Self Steam {Rosenberg self steam scale (RE

30. S)}.
This study was approved by Ethical Committee of Kerman Medi
cal
Sciences University.
Statistical analysis
Descriptive statistics were used to summarise the data. A
series of multifactorial logistic regression models were applied t
o
identify the factors that
influence each of the outcomes or body
management methods (i.e., diet, exercise). The results are
presented in terms of the odds ratio (OR), associated
95%‐
confidence intervals (CI), and P‐value.
In addition, the probability of outcomes was estimated from
developed logistic models. The estimated probabilities were the
n
compared with the observed individual’s status to
calculate the
correct classification proportion. P<0.05 was considered as
significant.
Results
About 48.5% (149) of 400 respondents were female. The mean
(SD) for age in three groups (general population,
university
students, gym users) were 27.6 (8.36), 23.13 (3.29), 22.09 (2.19
)
years, respectively. Some of demographic characteristics of
respondents were shown in Table 1. Mean of BMI in three group

31. s
were 23.75 (4.12), 49 (3.5), 22.90 (2.96) kg/m2 inprevious grou
ps
(Table 1). Frequencies of Body Dissatisfaction categories
in
participants were listed in Table 2.
Regarding the factors that encourage people to manage their
body shape through dieting, we find that pressure from relatives
(PSPS) (CI 95%: 0.83‐0.95, P=0.01, own comparison with
others
(PACS) (CI 95%: 1.01‐1.16, P=0.029), self steam (CI 95%: 1.01
‐1.38,
P=0.029) where are all influencing variables (Table 3). Belongi
ng to
specific group, and gender, there were no effect for
decision
regarding choose of body image strategies.
With respect to exercise, we find that gender (CI 95%: 0.19‐
0.68, P<0.001) and use of western TV (CI 95%: 1.16‐3.92, P=0.
014),
were important factors. It shows that other factors such as score
s
of PACS, and PSPS or other socio‐cultural variables, there were
not
influencing factors. Choosing of body management strategies ha
d
not affect by belonging to special groups.
Place of birth had significant effect on dieting (CI 95%: 1.35‐
13.01, P=0.013) and exercise (CI 95%: 0.12‐0.80,
P=0.016).
Participants who were born in big cities were 4.1 times more lik
ely

32. to manage their body shape through dieting. Born in big cities w
as
increased chance of using exercise as a body change
strategies
about 30% (Table 4).
Table 1. Demographic characteristics of respondents
Variable Level Frequency Percent
<20 85 21.2 Age
>20 315 78.8
Female 194 48.5 Gender
Male 206 51.5
Single 279 69.8 Marital status
Married 121 30.2
University degree 73 18.2 Education
High school or lower 327 81.8
Fair‐medium 246 61.5 Economic Status
Good‐excellent 154 38.5
Table 2. Distribution of body dissatisfaction
General
population
University
Students
Gym
users
Mild BD 14.3% 17.8% 8.0% Body

33. Dissatisfaction (BD) Severe BD 6.8% 9.5% 3.5%
BD=Body Dissatisfaction
Table 3. Identification of factors that encourage people to diet a
s a way
to manage their body shape through a multi factorial logistic reg
ression
Variable OR CI 95% P‐level
Age 0.50 0.39‐1.47 0.407
Gender 1.03 0.59‐1.79 0.931
Education 0.93 0.46‐1.90 0.85
Marital status 0.61 0.33‐1.10 0.102
Place of Birth 4.19 1.35‐13.01 0.013
Economic Status 1.74 1.0‐3.04 0.05
Western TV 0.66 0.39‐1.11 0.118
Study Group:
‐ Body building (gym )users
‐ University students
1.66
1.16
0.77‐3.61
0.61‐2.19
0.197
0.652

34. PSPS (Perceived Socio‐Cultural
Pressure Scale)
0.89 0.83‐0.95 0.01
PACS (Physical Appearance
Comparison Scale)
1.08 1.01‐1.16 0.029
BMI (Body Mass Index) 0.97 0.91‐1.05 0.474
Body Dissatisfaction (BD):
‐ Mild BD
‐ Severe BD
0.60
1.151.38
0.34‐1.06
0.53‐2.50
0.081
0.727
RES (Rosenberg Self Steam) 1.38 1.01‐1.38 0.029
Tharwat's Family

35. ISSN 2304-3415, Russian Open Medical Journal 2012; 1: 0308
3
Preventive medicine
[
© 2012, LLC Science and Innovations, Saratov, Russia
www.romj.org
Table 4. Identification of factors that encourage people to exerc
ise as a
way to manage their body shape through a multi factorial
logistic
regression
Variable OR CI 95% P‐level
Age 0.95 0.48‐1.90 0.888
Gender 0.36 0.19‐0.68 0.001
Education 0.54 0.23‐1.26 0.155
Marital status 2.09 1.01‐4.32 0.48
Place of Birth 0.30 0.12‐0.80 0.016
Economic Status 1.01 0.55‐1.40 0.979
Western TV 2.13 1.16‐3.92 0.014
Study Group:
‐ Body building (gym )users
‐ University students
1.30
1.49

36. 0.53‐3.19
0.74‐2.99
0.563
0.261
PSPS (Perceived Socio‐Cultural Pressure
Scale)
1.04 0.96‐1.12 0.34
PACS (Physical Appearance Comparison
Scale)
1.00 0.93‐1.08 0.953
BMI (Body Mass Index) 0.97 0.90‐1.05 0.479
Body Dissatisfaction (BD):
‐ Mild BD
‐ Severe BD
0.78
0.81
0.41‐1.46
0.36‐1.84
0.436
0.62
RES (Rosenberg Self Steam) 1.14 0.97‐1.35 0.124

37. Discussion
Among contributing factors that could be affect decision about
body change activities, body dissatisfaction is considered
as an
important factors. Body dissatisfaction is known significant
predictors of body change activities for women [14]. The desire
for
thinness as an appearance‐related reason for exercise is
associated with body dissatisfaction and low self‐esteem. In so
me
studies, however, body image dissatisfaction negatively correlat
ed
with physical activity, especially among adolescent girls [15]. S
ome
studies found that body satisfaction in women has a greater effe
ct
on self‐esteem than in men. Chronic dieters have increased body
dissatisfaction and lower self‐esteem [16]. It was surprising that
in
recent study, body dissatisfaction had no effect on body
management strategies. Body image and body satisfaction can b
e
affected by many socio‐cultural factors [8], that may be a greate
r
role in body change activities. Although this effect on dieting w
as
evident in both genders, dieting was more prominent in
males
[17]. However, according previous studies, we found that
self‐
esteem had contributing effect on body change activities
especially in dieting.

38. Socio‐cultural variables are important factors that
contribute
to body dissatisfaction and related problems such as
desire for
body management strategies. One of the socio‐cultural
factors
that may affect an individual’s desire to be thin or masculine an
d a
person’s decision regarding body change strategies is
perceived
pressure from family, friends and/or the media [8]. One
of the
social groups for comparison is the peer group. Peer groups hav
e a
significant effect on body satisfaction and body change activitie
s.
The effect of peers with ideal body types was associated
with
longer periods of exercise, especially for women.
Although this
comparison appears higher in females, peer effect on body
satisfaction and decisions about body changes are found
in both
genders [4]. In our study, dieting was influenced by
comparison
with others and family and peer pressures.
Body image is affected by environment and cultural issues. In
big cities, individuals are more prone to media or social pressur
e
such as fashion, magazines, beauty contest. In addition, in
big
cities, social situations and marriage could be related to attracti
ve
appearance [18]. Ideal body image is promoted through the medi

39. a
that suggests thinness is the sign of attractiveness.
Despite the
desire to
increase muscle mass, weight concerns and dieting are
also important for males [19]. Although heavy exercise was don
e
for weight loss achievement of masculinity especially for
male
adolescents. Effects of born in big cities and western TV. On bo
dy
management strategies were shown in recent study. Such
as
previous researches, gender could be an important factor
for
decision about body management. Belonging to specific
group,
there was no effect on body management activity. The reason of
this finding may be due to greater power of other
contributing
factors such as pressure from relatives, friends and media. Base
d
on this studies` results, body management strategies
in different
cultures were different.
Conclusion
Body image and related consequences such as body
change
activities are new issues in Iran. It seem socio‐cultural factors
are
important predictive factors for body change activities
.White

40. considering differences between Asian culture ,in
planning for
harm reduction of unhealthy behavior
in dieting or exercise ,
culture must be consider seriously. Future Asian
transcultural
studies about these differences are advised.
Acknowledgement: This research was financially supported
by
Neurosciences Research Center of Kerman University of Medica
l Sciences.
Conflict of interest: none declared.
Reference
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Authors:
Behshid Garrusi – MD, Associate Professor of Psychiatry,
Neuroscience
research center, Department of community medicine, Afzallipou
r Medical
School, Kerman University of Medical Sciences, Kerman, Iran;
Mohammad Reza Baneshi – PhD, Assistant Professor of
Statistics,
Research Center For Modeling in Health, Kerman
University of Medical
Sciences, Kerman, Iran;
Fatemeh Amiri – MD, Student Research Center, Kerman
University of
Medical Sciences, Kerman, Iran.

45. Copyright of Russian Open Medical Journal is the property of
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permission. However, users may print, download, or email
articles for individual use.
CLINICAL INQUIRIES From theFamily Physicians
Inquiries Network
How do exercise and diet
compare for weight
Evidence-based answer
Exercise alone produces short-term
weight loss that is comparable with that
induced by diet, after which a plateau in
weight loss appears to occur (strength
of recommendation [SOR]: B). Exercise
in combination with diet promotes
maintenance of weight loss above either
intervention alone in both obese and
overweight men and women (SOR: A).
Exercise-induced weight loss has been
Clinical commentary
shown to preferentially reduce abdominal
fat and increase lean skeletal muscle
compared with that induced by diet
(SOR: B).

46. Multiple short bouts of exercise per
day are as effective as a single long bout
in producing weight loss (SOR: B).
Adherence improves when exercise can
be completed at home or home equipment
is used (SOR: B).
The real challenge:
Motivating patients to exercise
The evidence is pretty clear. The real
challenge is motivating patients to start
and maintain an exercise plan. The key
points I make with my patients are: Aim
for 5 to 7 times each week. Start slowly
I Evidence summary
Exercise vs diet:
Some conflicting results
Studies comparing the effectiveness of
exercise and diet in weight reduction
have yielded conflicting results. Ear-
lier studies, including a meta-analysis
and randomized (noncontrolled) study,
favored interventions that included
caloric restriction (diet alone or diet
plus exercise). '̂̂̂̂
However, subjects on caloric re-
striction regained a significant amount
of weight over time (0.9 kg ± 7.7 at
2-year follow-up). Subjects who did
(10 minutes per session) and gradually
build (at least to 20 minutes within a few
months). Walking is often preferred, but
do what you enjoy. Having a "buddy" work

47. out with you may help you stick with it.
Henty Domke, MD
St. Mary's Health Center, Jefferson City, Missouri
aerobic exercise but did not diet lost less
weight initially (0.7 kg ± 2.8) but main-
tained their weight loss better than those
who dieted or dieted with exercise.
These earlier studies failed to control
for the confounding variable of energy
balance—that is, ensuring the amount of
calories reduced was comparable with
the amount of calories burned through
exercise between groups. A more recent
randomized controlled trial suggests
that aerobic exercise and caloric restric-
tion are equally beneficial in reducing
weight for obese men when controlling
for negative energy balance.^ However,
Stephanie Cudjoe, MD
and Shannon Moss, PhD
Baylor Family Medicine
Residency at Garland,
Garland, Texas
Loan Nguyen, MD
Baylor College of Medicine,
Houston, Texas
FAST TRACK
Exercise alone is
comparable with
diet for short-term

48. weight loss
www.jfponline.com VOL 56, NO 10 / OCTOBER 2007 8 4 1
CO
UJ
cc
O
<
o
o
How much exercise is best? Government agencies weigh in
PHYSICAL
ACTIVITY LEVEL
Moderate
Vigorous
(altemative)!
D H H S "
N H L B I '
Moderate

49. Moderate
ACTIVITIES
Bicyciing 5-9 mph, level terrain
or with a few hills, brisk walking,
golf, mowing lawn, recreational j
swimming, scrubbing floors/washing
windows, tennis (doubles), weight
lifting/Nautilus machines/free weights
Bicycling more than 10 mph
or on steep uphill terrain, circuit
training, moving/pushing furniture,
mowing lawn (hand mower),
racewaiking, jogging, running,
swimming laps, tennis (singies)
Bicycling (<10 mph), dancing, golf,
hiking, light gardening/yard work
stretching, walking (3.5 mph),
weight iifting (general light workout)
Basketball, bicyciing 5 miies/30 min,
gardening, running 10 min/mile,
social dancing, swimming laps,
walking 15-20 min/mile
DURATION
30 min
FREQUENCY
5 or more
days/week

50. NOTES
Ail adults
20 mm
60-90 min
30 min
3 or more
days/week
Daiiy
Daily
All adults
All adults attempting
to lose weight
Ali adults
FAST TRACK
Exercising at
home—or with a
"buddy"—should
help patients
adhere to
their regimen
those who exercised experienced great-
er fat reduction and maintenance of

51. skeletal muscle mass than those who
only restricted calories. Similar findings
regarding fat reduction have been re-
ported elsewhere."*
Combining diet and exercise ap-
pears to be superior to diet alone, based
on the results of a recent meta-analysis
of randomized controlled trials.^ How-
ever, this meta-analysis did not specify
type of exercise, so it is unclear whether
outcomes varied by activity.
Exercise: is there a
dose-response relationsiiip?
Several studies have looked at the rela-
tionship between duration and intensity
for exercise and weight loss. A dose-
response relationship has been observed
between the amount of time spent in aer-
obic exercise per week and the amount
of weight lost for overweight women. '̂̂̂̂
There appears to be no significant
difference in weight loss based on dura-
tion of a single aerobic exercise episode;
rather, weight loss is similar whether
completed in short or long bouts.̂̂ -^ One
study found that at 12 months, individ-
uals exercising more than 200 minutes
per week lost 7.8 kg more (P<.01) than
those exercising less than 150 minutes
per week.^ Another study noted that
at 18 months, subjects exercising more
than 200 minutes per week lost 9.6 kg

52. more than subjects exercising less than
150 minutes per week (P<.05).*
Studies with energy expenditure,
rather than time spent exercising, as the
independent variable had similar results.
At 18 months, individuals with higher
energy expenditure (2500 kcal/week)
lost 6.7 kg ± 8.1 compared with a mean
loss of 4.1 ± 8.3 in subjects with lower
energy expenditure (maximum of 1000
kcal/week).^
Recommendations from others
The National Institutes of Health's Na-
tional Heart, Lung and Blood Institute,'"
the US Department of Health and Hu-
man Services," the Centers for Disease
842 VOL 56, NO 10 / OCTOBER 2007 THE JOURNAL OF
FAMILY PRACTICE
-e s s u r-e'
Patients should be counseled that this product does not protect
against HIV intection.(AIDS) or other sexually
transmitted diseases.
IMPORTANT NOTE—This information is a BRIEF StJMMARY
of the complete prescribing information
(Instructions for Use) provided with the product and therefore
should not be used as the basis for prescrltjing
the product. This summary was prepared by deleting from the
compiete Instructions for Use certain text,
tables, arid references. The physician shouid be thoroughiy

53. famiiiar with the complete Instructions for Use
before using or prescribing this product.
INDiCATIOhlS FOR USE: The Essure system is indicated for
women who desire permanent birth controi
(female sterilization) by biiaterai occiusion of the faiiopian
tubes.
CONTRAiNDICATIONS:
The Essure system should not be used in any patient who:
• is uncertain about her desire to end fertility
• Can have only 1 micro-insert placed (inciuding patients with
apparent contraiateral proximal tubai occiusion
and patients with a suspected unicornuate uterus)
• Has previously undergone a tubal iigation
Or any patient with any of the foiiowing conditions:
• Pregnancy or suspected pregnancy
• Delivery or termination of a pregnancy iess than 6 weeks
before Essure micro-insert piacement
• Active or recent upper or iower pelvic infection
• Known aiiergy to contrast media or known hypersensitivity to
nickei confirmed by skin test
WARNINGS:
• The patient must use alternative contraception (cannot reiy on
the Essufe micro-inserts for contraception)
untii a hysterosaipingogram(HSG), which is performed 3
months post-micro-insert piacement, demon-
strates satisfactory micro-insert iocation and tubai occlusion.
During this time frame, the patient
may be at an increased risk of ectopic pregnancy

54. • The EssuK procedure should be considered irreversibie. There
are no data on the safety or effectiveness
of surgery to reverse the Essure procedure. Any attempt at
surgicai reversai wiil iikeiy require utero-
tubai reimplantation. Pregnancy foiiowing such a procedure
carries with it the risk of uterine rupture
and serious maternai and fetal morbidity and mortaiity
• The Essure micro-insert wiii conduct energy if directiy or
closeiy contacted by an active eiectro-
surgicai device, if this occurs, then there is a risk of patient
injury. Theretore, eiectrosurgery shouid
be avoided in procedures undertaken on the uterine cornua and
proximai fajiopian tubes without either
hysteroscopic visuaiization of the micro-inserts, or visuaiization
of the proximai portion of the faiiopian
tube via open surgical procedures or laparoscopy. During
Laparoscopic Assisted Vaginai Hysterectomy
(LAVH) and other procedures in which electrosurgicai
instruments couid contact the serosa of the
faiiopian tube, instruments should not be piaced more proximal
than the ampuilary portion of the tube
• Bench studies suggest that endometrial abiation using radio
frequency (RF) energy wili cause significant
damage to surrounding tissue if an active RF instrument comes
into direct contact with the Essure
micro-inserts. Consequently, if using RF energy to perform
endometrial abiation, direct contact with the Essure
micro-inserts shouid be avoided. Ciobai auto-abiative systems
that empioy RF energy should not be used in
women with the Essure micro-inserts in piace
• Bencti and ciinicai studies demonstrated that thermal
endometriai ablation of the uterus can be safely and

55. effectiveiy performed with the Gynecare THERMACHOICE'
Uterine Baiioon System immediateiy foiiowing
Essure micro-insert piacement. No specific studies have been
conducted to evaiuate Essure expuision rates
or contraception rates foiiowing fssure-THERMACHOICE
procedures. No other thermal endometriai
abiation teciinologies have been studied in conjunction with
Essure
' There are no data regarding cryoabiation techniques or the use
of iaser for endometriai abiation of the uterus
with the Essure micro-inserts in place
• There are aiso no data regarding the use of endometrial
ablation devices that operate at microwave
frequencies with the Essure rtiicro-inserts in piace. The use of
microwave energy near metallic impiants
has been shown to pose significant risk of serious injury to
patients. Use of microwave endometrial ablation
devices near the Essure micro-inserts therefore should be
avoided
• Aithough not reported in the ciinicai trials of the fssure
system, there is a theoreticai increased risk of ectopic
pregnancy in patients with the Essure micro-inserts, shouid they
become pregnant
• A very smali percentage of women in the Essure ciinicai triais
reported recurrent or persistent peivic
pain, and oniy 1 Vî oman requested device rerrioval due to pain.
However, if device removai is required for
any reason, it wiil iikeiy require surgery, inciuding an
abdominai incision and generai anesthesia,
and possibie hysterectomy
• Patients may decide, in future years, to undergo in vitro

56. fertiiization (iVF) to become pregnant. The effects
of the Essure micro-inserts on the success of iVF are unknown,
if pregnancy is achieved, the risks of the
micro-insert to the patient, to the fetus, and to the continuation
of a pregnancy are also unknown
PRECAUTIONS:
• Women should be counseled that:
—No contraceptive is 100% effective. Ectopic and intrauterine
pregnancy can occur in contraceptive failure,
even years after the procedure
—Data on the Essure micro-inserts beyond 5 years are not yet
avaiiabie and may be different from current data
—Women who undergo steriiization at a reiativeiy young age
are at greater risk of regretting their decision
to undergo sterilization
•Any intrauterine procedure performed without hysteroscopic
visualization following Essure micro-
insert impiantation couid interrupt the abiiity of the Essure
micro-inserts to prevent pregnancy. Foiiowing
such procedures, device retention and iocation shouid be
verified by hysteroscopy, x-ray, or ultrasound.
In addition, the presence of the Essure micro-inserts can invoive
risks associated with intrauterine
procedures that, at this time, have not been identified
• Performing endomefriat ablation irrimediately foiiowing
piacement of Essure micro-inserts may increase
the risk of post-ablation tubal sterilization syndrome, a rare
condition that has been reported in women
with a history of tubai steriiization who undergo endometriai
ablation

57. • Testing to ensure safety and compatibiiity with magnetic
resonance imaging (MRi) has been conducted
using a 1.5 testa magnet. The Essure micro-inserts were found
to be MR safe at this fieid strength. Test
resufe at 1.5 tesia indicate zero magnetic force and RF heating
of 0.6°C in a phantom when a whoie body
specitic absorption rate (SAR) of 1.3 W/kg was appiied. The
presence of the micro-inserts produces an fvlR
artifact, which wili obscure imaging of iocal tissue. The artifact
is expected to be iarger at higher fieid strength
ADVERSE EVENTS:
A total of 745 women underwent the Essure procedure in 2
separate ciinicai investigations to evaiuate the
safety and effectiveness of the fssuresystem (227 in the Phase II
study and 518 women in the Pivotai triai).
Some women underwent more than 1 procedure if successfui
biiaterai piacement was not achieved in the initiai
procedure. Placement of at least 1 Essure micro-insert was
achieved in 682 women (206 in the Phase
II study and 476 in the Pivotal triai). Adverse events, which
prevented reiiance on the Essure device for con-
traception, were reported as foliows: failure to piace 2 micro-
inserts in first procedure (14%), initiai tubai
patency (3.5%), expuision (2.2%), perforation (1.8%), or other
unsatisfactory device iocation (0.6%). Ail ot
the patients who experienced tutial patency at the 3-month HSG
were found to have bilateral occlusion at a
repeat HSG performed at approximateiy 6 months after the
Essure procedure. In addition, all of the patients
wtio chose to undergo a second fssure procedure foiiowing a
micro-insert expulsion achieved successfui
micro-insert placement and were subsequently able to rely on
the Essure micro-inserts for confraception.
The most frequent adverse events and side effects reported as a

58. result of the hysteroscopic procedure to
piace the Essure micro-inserts were as foiiows: cramping
(29.6%), pain (12.9%), nausea/vomiting (10.8%),
dizziness/iightheadedness (8.8%), and bieeding/spotting (6.8%).
Hypervoiemia occurred in < 1 % of cases.
During the first year of reiiance on the Essure micro-inserts for
contraception (approximately 15 months
after micro-insert piacement). the foiiowing episodes were
reported as at ieast possibly reiated to the
fssuremicro-inserts: back pain (9.0%), abdominai pain (3.8%),
dyspareunia (3.6%). Aii other events occurred
in iess than 3% of women.
PATIENT INFORfHATION:
Please see Patient Information Booklet.
PHYSICIAN INFORMATION:
For complete prescribing information physicians should refer to
the Cssure System Instructions for Use.
Oonceptus Incorporated
331 East Eveiyn Avenue, Mountain View, CA 94041 USA
•Trademark of ETHiCON, INC. CC-0366 08Sep05F
CO
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59. Control and Prevention's Healthy People
2010^^ recommend between 30 to 90 min-
utes of daily moderate physical activity, and
that this activity be done at least 5 days a
week—or even 7 days per week—depending
on whether a person's goal is weight mainte-
nance or weight loss.
Another option, offered by the CDC, is
that people do 20 minutes of vigorous ac-
tivity 3 days or more per week. All of the
groups recommend staying within caloric
intake requirements (TABLE). •
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