INTRODUCTION AND CLASSIFICATION, CAUSES AND MANAGEMENT OF OBESITY

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A project entitled
“EFFECTS OF DIET AND PHYSICAL EXERCISE IN OBESITY”
By
PRATHIK
Project submitted to the
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
Bangalore, Karnataka.
In Partial fulfillment of the award of
Bachelor of Physiotherapy [B.P.T]
Under the guidance of
Dr.N.MAGESWARAN
ASSOCIATE PROFESSOR
SRINIVAS COLLEGE OF PHYSIOTHERAPYAND RESEARCHCENTRE
PANDESHWAR, MANGALORE
2014-2018

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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA
DECLARATION BY THE CANDIDATE
I hereby declare that this project entitled “EFFECTS OF DIET AND
PHYSICAL EXERCISE IN OBESITY” is a bonafide and genuine research work
carried out by me under the guidance of Dr.N.MAGESWARAN, Associate Professor Srinivas
College of Physiotherapy and Research Centre.
Date: Signature:
Place: Mangalore Name: PRATHIK

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CERTIFICATE BY THE GUIDE
This is to certify that the project entitled is “EFFECTSOF DIET AND
PHYSICAL EXERCISE IN OBESITY” is a bonafide project done by PRATHIK
in partial fulfillment of the requirement for the degree of Bachelor of Physiotherapy.
Date: Signature of the Guide:
Place: Mangalore Dr. N. MAGESWARAN
Associate Professor
Srinivas College of Physiotherapy
and Research Centre

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ENDORSEMENT BY THE PRINCIPAL
This is to certify that the project entitled is “EFFECTS OF DIET AND PHYSICAL
EXERCISE IN OBESITY” is a bonafide project done by the guidance of
Dr.N.MAGESWARAN Associate Professor Srinivas College of Physiotherapy and Research
Centre, Mangalore.
Date: Signature of Principal
Place: Mangalore Prof. DR. S. RAJASEKAR
Srinivas College of Physiotherapy and
Research Center

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ACKNOWLEDGEMENT
First and foremost I would like to thank GOD and my parents Mr. RAJ R.B and
Mrs. SUKALATHA and my brother Mr.KARTHIK SURAJ and my aunty Mrs.JYOTHI and
my beloved teachers for their valuable support and confidence throughout my study.
I am thankful to our respected chairman and Managing Director Shri. A. Raghavendra
Rao and Vice President Shri. A. Srinivas Rao for all the facilities extended to me for the study.
I wish to express my thanks to my Respected Principal Prof. DR.S.RAJASEKAR
Srinivas college of Physiotherapy & Research Centre, Pandeshwar, Mangalore for his support
and help.
I wish to express my gratitude thanks to my respectable Guide Dr.N. MAGESWARAN
Associate professor Srinivas College of Physiotherapy and Research centre, Pandeshwar,
Mangalore for his valuable guidance and keen interest shown in this project work and without
whom this work would have not taken shape.
I wish to express my thanks to my class coordinator Dr.Prameela and Dr.Thrishala
and I wish to express my gratitude to my respected teachers Dr.Anisha , Dr.Komal , Dr.Prasad
, Dr.Deepak , Dr.Shruthi , Dr.Ilona , Dr.Radika , Dr.Kulal and Usha mam .
I wish to express my gratitude thanks to my librarian, Srinivas college of physiotherapy
and Research centre, Pandeshwar, Mangalore for providing books extended to me for the study.
I would like to thank once again to all who have helped me all the while.
Date: Signature:
Place: Mangalore Name: PRATHIK

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INDEX
SR NO. TITLE PAGE NO.
LIST OF ABBREVIATIONS 7
1. INTRODUCTION TO OBESITY 8-9
1.1) AEITIOLOGY 9-11
1.2) CRITERIA FOR OBESITY 12-13
2. CATEGORIES AND TYPES 13-16
3. PATHOPHYSIOLOGY OF OBESITY 17-18
4. ENERGY BALANCE AND WEIGHT MANAGEMENT 19
5. DIET AND EFFECTS 20-26
6. DIET GUIDELINES FOR OBESITY 27-32
7. EXERCISE AND EXERCISE PLANNING FOR OBESITY 33-35
8. MECHANISM/PATHOPHYSIOLOGY OF EXERCISES HELPING
IN BURNING FAT
36
9. FAT METABOLISM 37
10. EXERCISE PRESCRIPTION AND PROGRAMES FOR OBESITY 38-41
11. OBESITY EXERCISE TESTING 42
12. EFFECTS OF EXERCISE 43-45
13. TYPES OF PHYSICAL FITNESS 46
14. RECOMMENDED WEIGHT LOSS PROGRAMS 47
15. SUPPLEMENTS 47-50
16. REVIEW OF LITERATURE 51-55
17. CONCLUSION 56
18. REFERENCES 57-60

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LIST OF ABBREVIATIONS
T2D Type 2 diabetes
CVD Cardiovascular disease
BMI Body mass index
DXA Dual-energy X-ray absorptiometry
FAS Fatty acid synthase
DIO Diet-induced obese
RT Resistance training
AT Aerobic training
CT Combine training
CON Control Group
ROM Range of motion
5-HT 5-hydroxytryptamine
TPH Tryptophan hydroxylase
MRI Magnetic resonance imaging
cAMP Cyclic adenosine monophosphate

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INTRODUCTION
1.OBESITY
Obesity, which is broadly defined as excess body weight for a given height, remains a
continuing global health concern, as it is associated with increased risk of numerous chronic
diseases including type 2 diabetes (T2D), hypertension, and cardiovascular disease (CVD). Body
mass index (BMI) (weight in kg/height in m2), the most widely used formula to define
overweight (BMI 25 to 29.9 kg/m2) and obesity (BMI $30 kg/m2), while not being a true
measure of adiposity, is simple to use in health screenings and epidemiological surveys. A recent
analysis of data from 195 countries revealed that the prevalence of obesity has doubled in more
than 70 countries since 1980, and over 600 million adults were obese in 2015, with high BMI
accounting for 4 million deaths globally 1.
It is a condition of excessive accumulation of fat in fat depots resulting in more than 20%
excess of expected body weight2. In its simple terms, obesity can be considered to result from an
imbalance between the amount of energy consumed in the diet and the amount of energy
expended through exercise and bodily functions. Obesity is widely regarded as a pandemic, with
potentially disastrous consequences for human health. This is an important nutritional disorder
mainly in the rich communities of the world and is not a problem in our country3.
Obesity is a long term process. Obesity frequently begins in childhood. Obese parents
likely have overweight children. Regardless of final body weight as adults, overweight children
exhibit more illnesses as adults than normal kids3.

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Obesity has a multifactorial nature resulting from genetic, epigenetic, physiological,
behavioral, sociocultural, and environmental factors that lead to an imbalance between energy
intake and expenditure during an extended time period. The importance of less sleep, endocrine
disruptors such as some chemicals in food packaging and foods increased time in climate-
controlled areas, cessation of smoking, weight gain that is associated with some medications,
older parental age at birth, and intrauterine and intergenerational effects have been reported as
contributors to the obesity epidemic4.
Obesity shortens life span and affects the function of many organ systems (appendix).
Mortality results from several diseases that are associated with obesity, including diabetes,
chronic kidney disease, gastro intestinal disease, and cardiovascular disease and maintaining
weight loss is often difficult or unsuccessful4.
There is increasing public awareness of the health implications of obesity. Many patients
will seek medical help for their obesity, others will present with one of the complications of
obesity, and increasing numbers are being identified during health screening examinations3.
Increases in adipose tissue occur in two ways:
1. Fat cell hypertrophy
2. Fat cell hyperplasia
Total number of fat cells increases 3 general periods:
I. Last trimester pregnancy
II. 1’st year life
III. Adolescence.
1.1 AETIOLOGY
Age: All ages
Sex: Both
Family: history may be positive in some cases.
• Physical activity
The disease is very common in persons with sedentary habit than in persons with active habit.

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 Family lifestyle
Obesity tends to run in families. If one or both of parents are obese, risk of being obese is
increased. That's not just because of genetics. Family members tend to share similar eating and
activity habits5.
 Psychological factor
As a result of emotional unstability overeating may develop as a habit which may lead to obesity.
 Economic background
It is common amongst the rich in our country who consume lots of protein, fat and carbohydrate
in their diet.
 Endocrinal causes
In cases of hypothyroidism, Cushing’s syndrome, adiposogenital dystrophy, etc., there may be
obesity. But certainly these causes are very rare2.
 Pregnancy
During pregnancy a woman may develop adiposity increasing the body weight to about 4-5 Kg
and this may go on increasing in subsequent pregnancies.
 Genetic factor
Obesity develops in Prader-Willi syndrome.
Laurence – Moon - Biedl syndrome, etc.
 Hypothalamic syndrome
Lesions in the hypothalamus may give rise to polyphagia and subsequent obesity.
 Genetic influence
This has been recently shown from various studies that Genetic influence has been found to
operate in as much as 50%-70% of the cases of obesity.
Existence of a gene similar to “Leptin” in experimental mice has been found. Energy intake and
energy expenditure both can be explained by this genetic factor 2.

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 Inactivity
If you're not very active, you don't burn as many calories. With a sedentary lifestyle, you can
easily take in more calories every day than you burn through exercise and routine daily
Activities5.
 Unhealthy diet
A diet that's high in calories, lacking in fruits and vegetables, full of fast food, and laden with
high-calorie beverages and oversized portions contributes to weight gain5.
 Certain medications
Some medications can lead to weight gain such as some antidepressants, anti-seizure
medications, diabetes medications, antipsychotic medications, steroids and beta blockers5.
 Quitting smoking
Quitting smoking is often associated with weight gain.
 Lack of sleep
Not getting enough sleep or getting too much sleep can cause changes in hormones that increase
your appetite. You may also crave foods high in calories and carbohydrates, which can
contribute to weight gain5.
 Characteristics of fast food linked to increased adiposity:
1. Higher energy density
2. Greater saturated fat
3. Reduced complex carbohydrates & fiber
4. Reduced fruits and vegetables

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1.2 CRITERIA FOR OBESITY
1. Body weight more than 20% above the ideal body weight
2. Ponderal index less than 12.
Ponderal index = Height in inches / ∛weight in lb
2
3. A fatfold thickness greater than 2.5 cm at the tip of scapula in males or mid triceps region
in females6.
4. Body composition measurement: Central fat (an approximation of visceral fat) was
evaluated using always Dual-energy X-ray absorptiometry (DXA). Measuring the fat
percentage within a defined rectangle, from the upper edge of the second lumbar vertebra
to the lower edge of the fourth lumbar vertebra. The vertical sides of this rectangular area
were the continuation of the lateral sides of the rib cage7.
5. Waist circumference (or waist-to-height ratio) used to measure central adiposity or
visceral fat7. Waist circumference is measured with a flexible tape placed on a horizontal
plane parallel to the floor at the level of the iliac crest, fitting snugly without compressing
the skin at the end of normal exhalation. In patients with a BMI of 35 kg/m2 or greater,
waist measurement is unnecessary as a screening tool since the majority of these patients
have central adiposity. Additionally, there is a different criterion for obesity using waist
measurement in Asian women8.
6. Body Mass Index (BMI) is a simple index of weight-for-height that is commonly used to
classify underweight, overweight and obesity in adults. It is defined as the weight in
kilograms divided by the square of the height in metres (kg/m
2
)4,2. For example, an adult
who weighs 70kg and whose height is 1.75m will have a BMI of 22.9.
Grading of obesity based on Body mass index (BMI)
Body mass index = weight (kg)/height squared (m
2
).
Normal range = 20-25
Grade 1 obesity = 25-30
Grade 2 obesity = 30-40
Grade 3 obesity = > 40

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2.CATEGORIES AND TYPES :
Types of obesity according to BMI:
Classification BMI(kg/m
2
)
Principal cut-off points Additional cut-off points
Underweight <18.50 <18.50
Severe thinness <16.00 <16.00
Moderate thinness 16.00 - 16.99 16.00 - 16.99
Mild thinness 17.00 - 18.49 17.00 - 18.49
Normal range 18.50 - 24.99 18.50 - 22.99
23.00 - 24.99
Overweight ≥25.00 ≥25.00
Pre-obese 25.00 - 29.99 25.00 - 27.49
27.50 - 29.99
Obese ≥30.00 ≥30.00
Obese class I 30.00 - 34.99 30.00 - 32.49
32.50 - 34.99
Obese class II 35.00 - 39.99 35.00 - 37.49
37.50 - 39.99
Obese class III ≥40.00 ≥40.00

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Types of obesity according to shape:

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Elevated body mass index, particularly caused by abdominal or upper-body obesity, has been
associated with a number of diseases and metabolic abnormalities, many of which have high
morbidity and mortality. These include hyperinsulinemia, insulin resistance, type 2 diabetes,
hypertension, dyslipidemia, coronary heart disease, gallbladder disease, and certain
malignancies9.

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Obesity: Weight 20% greater than ideal body weight.
Morbid obesity: Weight 100% greater than ideal body weight.
Malignant obesity: Weight 200% greater than ideal body weight.
Central obesity: Central obesity is sometimes defined as a waist: hip ratio greater than 0.95 in
men and 0.85 in women. A simpler indicator used in a WHO report is that increased risk is
present when the waist circumference exceeds 37 inches for men or 32 inches for women10.

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3.PATHOPHYSIOLOGY OF OBESITY :
Increased caloric intake and decreased activity results in an excess of calories that is stored as
large adipose deposits. Certain medications, endocrine disorders, and lifestyle also contribute to
obesity8. Additionally, according to Bray, heredity may play a role in obesity citing studies of
twins11.
Interestingly, the pathogenesis of obesity includes current research on genetic
components related to satiety, food cues, and increased food intake in obese versus persons of
normal weight. Several genetic models currently exist; Agouti gene, leptin, leptin receptor gene
to name a few. A limited discussion on the role of genes will be included here8.
Karra etal.12, found a genetic predisposition involved in increased ad-lib food intake,
“particularly fat consumption and impaired satiety.” Additionally, frequent exposure to a high fat
diet leads to an up-regulation in the fat mass and obesity-associated gene (FTO), which in turn
leads to increased fat intake. According to Bray11, “A variant in the FTO gene on chromosome
16 predisposes to type 2 diabetes through an effect on BMI.” This variant is thought to contribute
to approximately 22% of common obesity.
FTO regulates ghrelin, a hormone secreted in the gut that alters appetite and food intake.
When ghrelin is increased, reduced satiety and increased food intake ensue12. Surprisingly, FTO
also affects human responses to food images. In their 2013 study, Karra et al. found high calorie
food images were rated significantly more appealing in post-prandial subjects with higher ghrelin
levels12. Their findings indicate that altered ghrelin levels may contribute to increased appetite
and food intake, especially fatty foods. It has been found that increased levels of ghrelin occur
after diet-induced weight loss and this may explain the difficulty in maintaining the loss of
weight8. Other hormones also play a role in weight gain. For example, in women, increased
serum testosterone and decreased estrogen and growth hormone contributes to an increase in
visceral fat and may help explain the weight gain associated with menopause11.
Leptin is an important component in the long term regulation of body weight. Recent
studies with obese and non-obese humans demonstrated a strong positive correlation of serum
leptin concentrations with percentage of body fat. It appears that as adipocytes increase in size
due to accumulation of triglyceride, they synthesize more and more leptin. Leptin's effects on
body weight are mediated through effects on hypothalamic centers that control feeding behavior
and hunger, body temperature and energy expenditure13.
Besides the generally accepted role of adipocytes for fat storage, these cell also release
endocrine-regulating molecules. These molecule include: energy regulatory hormone (leptin),
cytokines(TNF-α and interleukin-6), insulin sensitivity regulating agents (adiponectin, resistin
and RBP4), prothrombotic factors (plasminogen activator inhibitor), and blood pressure
regulating agent(angiotensinogen)14.

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4. ENERGY BALANCE AND WEIGHT MANAGEMENT.
Energy intake and energy expenditure are the two main components of energy balance.
When energy intake exceeds energy expenditure, adipocytes enlarge for the excess storage of
energy and results in weight gain. When energy intake is less than energy expenditure, the body
mobilizes its energy reserves to meet the energy deficit and results in weight loss15.

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5.DIET AND ITS EFFECTS:
Diet:
Diet is a word that has several meanings. Anyone who has tried to lose weight has no
doubt been on a diet. In this sense, diet means weight-reducing diet and is often thought of in a
negative way. But a more general definition of diet is the foods and beverages you normally eat
and drink16,17.
Diet is an obvious target for intervention, as reduction in energy intake can lead to
negative energy balance and weight loss. Different types of diets are proposed to promote weight
loss such as low-calorie and fat-restricted diets and low-carbohydrate diets18.
Low - carbohydrate dietary pattern may be most effective in inducing weight loss in the short
term.
 Nutrition
A science that studies nutrients and other substances in foods and in the body and
the way those nutrients relate to health and disease. Nutrition also explores why you
choose particular foods and the type of diet you eat16.
 Nutrients
The nourishing substances in food that provide energy and promote the growth and
maintenance of your body. There are about 50 nutrients that can be arranged into six classes,
as follows16:
1. Carbohydrates
2. Fats (lipids)
3. Protein
4. Vitamins
5. Minerals
6. Water
Carbohydrates – A large class of nutrients including sugar, starches, and fibers that are the body's
primary source of energy.
Lipids (fats) – A group of fatty substances including triglycerides and cholesterol that are not
soluble in water and that provide a rich source of energy and structure to the body's cells.
Proteins – Major structural part of body's cells composed of nitrogen-containing amino acids,
particularly rich in animal foods. Both vitamins and minerals are essential in small amounts to
maintain the body, regulate body processes, and for growth and reproduction.

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Vitamins – 13 noncaloric nutrients found in a wide variety of foods (especially fruits and
vegetables)
Minerals – Noncaloric, inorganic chemical substances found in a wide variety of foods.
Water – Inorganic nutrient that plays a vital role in all bodily processes and makes up just over
half of the body's weight.
Carbohydrates, lipids, and protein are called energy-yielding nutrients because they can
be burned as fuel to provide energy for the body. They provide kcalories as follows19:
Carbohydrates: 4 kcalories per gram
Lipids: 9 kcalories per gram
Protein: 4 kcalories per gram
The body needs vitamins and minerals in small amounts, and so these nutrients are called
micronutrients (micro means small). In contrast, the body needs large amounts of carbohydrates,
lipids, and protein, and so they are called macronutrients (macro means large)19.
TYPES OF DIET:
CARBOHYDRATES:
Carbohydrates are the primary source. They are the least expensive and most abundant of
the energy nutrients. Foods rich in carbohydrates grow easily in most climates. They keep well
and are generally easy to digest20.

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Types of carbohydrates:
I. Monosaccharides
II. Disaccharides
III. Polysaccharides
IV. Complex polysaccharide
Functions:
• It is a major energy source, particularly during high-intensity exercise.
• Its presence regulates fat and protein metabolism.
• The nervous system relies exclusively on carbohydrate for energy.
• Muscle and liver glycogen are synthesized from carbohydrate12.
• Providing fiber in the diet is another important function of carbohydrates. Dietary fiber is
found in grains, vegetables, and fruits. Fiber creates a soft, bulky stool that moves quickly
through the large intestine20.
PROTEINS:
Proteins are primary structural and functional components of every living cell. Almost
half the protein in our body is in the form of muscle and the rest of it is in bone, cartilage and
skin. Proteins are complex molecules composed of different amino acids. Certain amino acids
which are termed “essential”, have to be obtained from proteins in the diet since they are not
synthesized in the human body. Other nonessential amino acids can be synthesized in the body to
build proteins. Proteins perform a wide range of functions and also provide energy (4 Kcal/g) 21.

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TYPES OF PROTEIN:
I. Simple proteins
II. Conjugated proteins
III. Derived protein
Amino acids:
Amino acid
Essential Nonessentialessential
Isoleucine Alanine
Leucine Arginine
Lysine Asparagine
Methlonine Aspartic acid
Phenylalanine Cysteine
Threonine Glutamic acid
Tryptophan Glutamine
Valine Glycine
Histidine (children)a Proline
Serine
Tyrosine
Histidine (adult)
Histidine is not synthesized in infants and young children, so it is an essential amino acid for
children but not for adults.
Function of Protein:
• It is the major structural component of the cell.
• It is used for growth, repair, and maintenance of body tissues.
• Hemoglobin, enzymes, and many hormones are produced from protein.
• It is one of the three primary buffers in the control of acid–base balance.
• Proteins in the plasma help maintain normal blood osmotic pressure.
• Antibodies for disease protection are formed from protein.
• Energy can be produced from protein21.

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Lipids or Fat:
Amino AcidsThe word lipid is derived from lipos, a Greek word for fat. Forms of this word are
found in several fat-related health terms such as blood lipids (fats in the blood), hyperlipidemia
(high levels of fat in the blood), and lipoproteins (carriers of fat in human blood).
Fats are greasy substances that are not soluble in water. They are soluble in some solvents
such as ether, benzene, and chloroform. They provide a more concentrated source of energy than
carbohydrates; each gram of fat contains 9 calories. This is slightly more than twice the calorie
content of carbohydrates.
Fat-rich foods are generally more expensive than carbohydrate-rich foods. Like
carbohydrates, fats are composed of carbon, hydrogen, and oxygen but with a substantially lower
proportion of oxygen20.
TYPES OF LIPIDS:
1. Simple lipids
2. Compound lipids
3. Waxes
4. Derived lipids

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Functions of Lipids:
 To provide energy.
 Fats are essential for the functioning and structure of body tissues.
 Fats are a necessary part of cell membranes (cell walls). They contain essential fatty acids
and act as carriers for fat-soluble vitamins A, D, E, and K.
 The fat stored in body tissues provides energy when one cannot eat, as may occur during
some illness and after abdominal surgery.
 Adipose (fatty) tissue protects organs and bones from injury by serving as protective
padding and support.
 Body fat also serves as insulation from cold
 Fats provide a feeling of satiety (satisfaction) after meals. This is due partly to the flavor
fats give other foods and partly to their slow rate of digestion, which delays hunger20.
ADEQUATE DIET:
A diet that provides enough kcalories , essential nutrients, and fiber to keep a person
healthy.
Nutritionally adequate diets are essential for normal growth and development and play an
important role in lowering disease risk, including both communicable and noncommunicable
chronic diseases22.
MODERATE DIET :
A diet that avoids excessive amounts of kcalories or any particular food or nutrients.
BALANCED DIET :
A diet in which foods are chosen to provide kcalories , essential nutrients, and fiber in the
right proportions.
A balanced diet to provide an energy deficit of 500 –1,000 kcal/day from daily energy
requirement. Daily calorie requirement was determined by estimating resting energy expenditure
and multiplying the obtained value by 1.3. The diet contained ~30% of energy as fat, 50% as

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carbohydrate, and 20% as protein. Total calorie intake was adjusted so that the weight loss was
regulated at a rate of ~0.4–0.9 kg (1–2 lb per week)23.
VARIED DIET :
A diet in which you eat a wide selection of foods to get necessary nutrients.

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6.DIET GUIDELINES FOR OBESITY:
DIET GUILDLINES24
1. Eat variety of foods to ensure a balanced diet.
2. Ensure adequate and appropriate diets for children and adolescents, both in health and
sickness.
3. Eat plenty of vegetables and fruits.
4. Ensure moderate use of edible oils and animal foods and very less use of ghee/ butter/
vanaspati.
5. Avoid overeating to prevent overweight and obesity.
6. Exercise regularly and be physically active to maintain ideal body weight.
7. Restrict salt intake to minimum.
8. Ensure the use of safe and clean foods.
9. Adopt right pre-cooking processes and appropriate cooking methods.
10. Drink plenty of water and take beverages in moderation.
11. Minimize the use of processed foods rich in salt, sugar and fats.
12. Include micronutrient-rich foods in the diets of elderly people to enable them to be fit and
active.
Reduced Dietary Energy Intake
To achieve weight loss, an energy deficit is required. The techniques for reducing dietary energy
intake include the following25:
 Specification of an energy intake target that is less than that required for energy balance,
usually1,200 to 1,500 kcal/d for women and 1,500 to 1,800 kcal/d for men (kilocalorie
levels are usually adjusted for the individual’s body weight and physical activity levels);
 Estimation of individual energy requirements according to expert guidelines and
prescription of an energy deficit of 500 kcal/d or 750 kcal/d or 30% energy deficit; and
 Ad libitum approaches, in which a formal energy deficit target is not prescribed, but
lower calorie intake is achieved by restriction or elimination of particular food groups or
provision of prescribed foods.
Energy Intake was not different between conditions at lunch (control: 2,9306203;
20% reduction condition: 2,8536198; 40% reduction condition: 2,9116179 kJ) or over the
whole day except breakfast (control: 7,3746361; 20% reduction condition: 7,5666468;

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40% reduction condition: 7,4136417 kJ) . Daily EI including breakfast was 10,2876395
kJ, 9,8976491 kJ, and 9,1616437 kJ in control, 20% reduction and 40% reduction
conditions respectively25.
A variety of dietary approaches can produce weight loss in overweight and obese adults. All of
the following dietary approaches (listed in alphabetical order) are associated with weight loss if
reduction in dietary energy intake is achieved26:
 A diet from the European Association for the Study of Diabetes Guidelines, which
focuses on targeting food groups, rather than formal prescribed energy restriction, while
still achieving an energy deficit. Descriptions of the diet can be found in the Full Panel
Report supplement.
 Higher-protein diet (25% of total calories from protein, 30% of total calories from fat,
and 45% of total calories from carbohydrate), with provision of foods that realize an
energy deficit.
 Higher-protein ZoneTM - type diet (5 meals/d, each with 40% of total calories from
carbohydrate, 30% of total calories from protein, and 30% of total calories from fat)
without formal prescribed energy restriction but with a realized energy deficit.
 Lacto – ovo –vegetarian – style diet with prescribed energy restriction.
 Low-calorie diet with prescribed energy restriction.
 Low-carbohydrate diet (initially <20 g/d carbohydrate) without formal prescribed energy
restriction but with a realized energy deficit.
 Low-fat vegan-style diet (10% to 25% of total calories from fat) without formal
prescribed energy restriction but with a realized energy deficit.
 Low-fat diet (20% of total calories from fat) without formal prescribed energy restriction
but with a realized energy deficit.
 Low–glycemic–load diet, either with formal prescribed energy restriction or without
formal prescribed energy restriction, but with realized energy deficit.
 Lower-fat (_30% fat), high-dairy (4 servings/d) diets with or without increased fiber
and/or low glycemic- index (low–glycemic-load) foods with prescribed energy
restriction.
 Macronutrient-targeted diets (15% or 25% of total calories from protein; 20% or 40% of
total calories from fat; 35%, 45%, 55%, or 65% of total calories from carbohydrate) with
prescribed energy restriction.
 Mediterranean-style diet with prescribed energy restriction.
 Moderate-protein diet (12% of total calories from protein, 58% of total calories from
carbohydrate, and 30% of total calories from fat) with provision of foods that realize an
energy deficit.
 Provision of high–glycemic-load or low–glycemic load meals with prescribed energy
restriction.
 The AHA-style Step 1 diet (prescribed energy restriction of 1,500 to 1,800 kcal/d, <30%
of total calories from fat, <10% of total calories from saturated fat).

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Low-Fat Approaches
In overweight and obese adults, there is comparable weight loss at 6 to 12 months with
instruction to consume a calorie-restricted (500- to 750-kcal deficit/d) lower-fat diet (<30% of
total calories from fat) compared with a higher-fat diet (>40% of total calories from fat).
Comprehensive programs of lifestyle change were used in all trials. Comparator diets had ≥40%
of total calories from fat, either with a low-carbohydrate or low-glycemic-load diet or one that
targets higher fat with either average or low protein26.
Low-Carbohydrate Approaches (<30 g/d)
In overweight and obese adults, there are no differences in weight loss at 6 months with
instructions to consume a carbohydrate-restricted diet (20 g/d for up to 3 months, followed by
increasing levels of carbohydrate intake up to a point at which weight loss plateaus) in
comparison with instruction to consume a calorie restricted, low-fat diet. The comparator diets
on which this statement is based were either a calorie-restricted, higher-carbohydrate, and lower-
protein diet (55% of total calories from carbohydrate, 30% of total calories from fat, and 15% of
total calories from protein) or a lower-fat European Association for the Study of Diabetes food
group dietary pattern (40% of total calories from carbohydrate, 30% of total calories from fat,
and 30% of total calories from protein)26.
Meal Replacement and Adding Foods to Liquid Diets
In overweight and obese women, the use of liquid and bar meal replacements is associated with
increased weight loss at up to 6 months, in comparison with a balanced deficit diet using only
conventional food. Longer term evidence of continued weight loss advantage is lacking.
Very-Low-Calorie Diet Approaches
There is insufficient evidence to comment on the value of liquid protein supplementation after
the very–low calorie diet induction of weight loss as an aid to weight loss maintenance.
Higher-Protein Approaches
(25% to 30% of Energy)
In overweight and obese adults, recommendations to increase dietary protein (25% of total
calories) as part of a comprehensive weight loss intervention results in weight loss equivalent to
that achieved with a typical protein diet (15% of total calories) when both diets are calorie
restricted (500- to 750-kcal/d deficit)26.
Higher-protein diets that contain between 1.2 and 1.6 g protein $ kg21 $ d21 and
potentially include meal-specific protein quantities of at least w25–30 g protein/meal provide
improvements in appetite, body weight management, and/or cardio metabolic risk factors
compared with lower-protein diets (Table 2). Although greater satiety, weight loss, fat mass loss,
and/or the preservation of lean mass are often observed with increased protein consumption in

30. 30
controlled feeding studies, the lack of dietary compliance with prescribed diets in free-living
adults makes it challenging to confirm a sustained protein effect over the long term27.
Examples of reduced-calorie diets for weight loss28.
Diet Description
Weight Watchers Point system based on food characteristics
encourages healthy choices Group support
available
Health Management Meal replacements, fruits, vegetables
Resources Diet Quick start and transition phases Lifestyle
training, weekly coaching, home or clinic
Biggest Loser Diet Books providing guidance on calorie
restriction and exercise
Jenny Craig Personalized prepackaged meal/exercise plan
with support of consultants with access to
expertise of registered dietitians
Raw Food Diet 75%-80% of daily foods are plant based and
not heated above 1158F or 46.18C Substantial
preparation time
Volumetrics Focus on low-density, high-volume foods
Atkins Low carbohydrate Frozen food line is available
Flexitarian Diet Mostly vegetarian Outlined 5-week meal plan
Slim-Fast Meal replacement program
Vegan Diet Excludes all animal products
 Weight loss diets often recommend targeted restriction of either carbohydrates or fat.
While low-fat diets were popular in the latter part of the 20th century, carbohydrate
restriction has regained popularity in recent years, with proponents claiming that the
resulting decreased insulin secretion causes elevated release of free fatty acids from
adipose tissue, increased fat oxidation and energy expenditure, and greater body fat loss
than restriction of dietary fat. One influential author concluded that ‘‘any diet that
succeeds does so because the dieter restricts fattening carbohydrates .Those who lose fat
on a diet do so because of what they are not eating the fattening carbohydrates’’. In other
words, body fat loss requires reduction of insulinogenic carbohydrates. This
extraordinary claim was based on the observation that even diets targeting fat reduction
typically also reduce refined carbohydrates. Since the primary regulator of adipose tissue
fat storage is insulin, and a reduction in refined carbohydrates reduces insulin,
carbohydrate reduction alone may have been responsible for the loss of body fat even
with a low-fat diet29.

31. 31
Dairy
Dairy, and particularly milk products are a source of high-quality protein which contain
all nine essential amino acids. The two main protein fractions found in milk are casein (80%) and
whey (20%), and are found in dairy and while they both contribute to suppressing short-term
food intake and increasing satiety, these two proteins differ mainly in the way they are digested
and absorbed. Casein has a slower rate of digestion with amino acids being slowly released into
the bloodstream, whereas whey is digested more rapidly, thus resulting in a greater increase in
plasma amino acids. Furthermore, dairy is also a rich source of calcium, an essential
micronutrient that must be acquired from food sources, or from a supplement15.
However, in the past decade, dairy consumption has garnered notice for its suggested
anti-obesity effect in facilitating weight loss and improving weight management. The very first
empirical evidence demonstrating an inverse association between a calcium-rich dairy based diet
and body mass index (BMI) was reported in the 1980s in a study of hypertensive humans. This
study showed a significant correlation between calcium intake and body mass index (BMI),
where a higher intake of calcium from dairy products was negatively correlated with BMI. Since
then, the ability of calcium and dairy products to regulate energy metabolism and body weight,
specific to changes in fat mass, has gained considerable attention. Yet, evidence of calcium
enriched dairy products in regulating adiposity is equivocal in both rodent and human studies.
Some studies show a reduction in both weight and fat mass during an energy restriction period,
and an attenuation in weight gain during an ad libitum feeding period, in both humans and
rodents, whereas others have reported no association or even an inverse correlation between
dairy intake and weight gain. A plausible explanation for these inconsistent findings could be
attributed to an overall increase in total energy intake with the added dairy15.
A first line of suggestion, introduced by Zemel et al highlighted a calcium-controlled
pathway in adipose tissue. Specifically, they suggested that dietary calcium and dairy foods
regulate adipocyte lipid metabolism and energy partitioning between adipose tissue and skeletal
muscle. In fact, calcitriol, the active form of vitamin D (1.25-dihydroxyvitamin D) is recognized
as a potent mediator of adipocyte lipid metabolism. In response to a low-calcium diet, calcitriol
stimulates a rapid influx of intracellular calcium into adipocytes, which in turn promotes
lipogenesis and inhibits lipolysis via an increase in fatty acid synthase (FAS) activity. On the
contrary, these effects can be reversed with a high-calcium diet. Specifically, it appears that
calcium decreases 1.25-dihydroxyvitamin D levels. This induces a shift from energy storage to
energy expenditure, in the partitioning of dietary energy, as lower levels of 1.25-
dihydroxyvitamin D levels promotes a decrease of adipocyte intracellular calcium, thus
stimulating adipocyte lipolysis and inhibiting lipogenesis . Interestingly, dietary calcium has also
shown to increase the up-regulation of WAT mitochondrial uncoupling protein 2 expression
(UCP 2) in an obese mouse model, a protein that is implicated in thermogenesis. Although the
mice on the high-calcium diet had an increase in core temperature in comparison to their low-
calcium fed mice counterparts, Shi al et note that the increased expression of WAT UCP 2 could
merely be a physiological consequence of lipolysis15.

32. 32
Combination Treatment: Dairy and Exercise
As dairy has been reported to induce similar effects to that of exercise in attenuating the
development of obesity , incorporating dairy as a nutritional strategy in conjunction with exercise
represents an ideal treatment approach to further potentiate the beneficial effects of exercise in
reducing/attenuating weight gain and WAT mass. To date, few human trials have examined the
therapeutic treatment combination of dairy and exercise in the context of weight loss. Based on
findings from Josse et al. increasing the consumption of dairy foods with an exercise and diet-
induced weight loss intervention promoted greater losses in total and visceral fat in obese
women, than those who consumed lower amounts of dairy while exercising. However, all
participants consumed a hypo-energetic diet, and dairy had no additional further effect in body
weight loss between both groups. As such, future work is required to validate these findings as
well as identify the long-term implications that can be drawn from these conclusions. Ideally,
what remains to be examined is the potential ability of dairy to augment the effects of exercise in
attenuating further weight gain15.
MEAL PLAN

33. 33
7.EXERCISE AND EXERCISE PLANNING FOR OBESITY
Exercise is a type of physical activity that requires planned, structured, and repetitive
bodily movement to improve or maintain one or more components of physical fitness. Examples
of exercise are walking, running, cycling, aerobics, swimming, and strength training. Exercise is
usually viewed as an activity that requires a vigorous-intensity effort30.
Types of Exercise:
1. Anaerobic and Aerobic Power Training Programs
 Interval Training
 Continuous Training
 Circuit Training
 Interval-Circuit Training

34. 34
2. Resistance Training Programs
 Static contractions,
 Dynamic contractions,
 Or Both.
 Dynamic contractions can include either or both concentric and eccentric contractions
using free weights, variable resistance, isokinetic actions, and plyometrics31.
3. Stretching exercise
An acceptable warm-up would begin with 5 to 10 min of stretching. And also after the cool-
down period, stretching exercises can be performed to facilitate increased flexibility31.
4. Neuromotor exercise: Balance, agility, coordination, gait, proprioception, and other
multifaceted activities such as Tai Chi and yoga32.
EXERCISE PLANNING FOR OBESITY
 Importance of exercise in obese population
The metabolic health promoting effects of exercise in both the prevention and treatment
of obesity are well established, and constitutes an important strategy in targeting weight loss.
Repeated bouts of exercise training leads to beneficial adaptations in whole body health,
including improvements in glucose tolerance and insulin sensitivity, and reducing
hyperlipidemia. These beneficial adaptations have important implications for individuals seeking
ways to improve their metabolic profile and prevent adiposity. In addition, regular exercise is
also an important component of energy balance. As such, exercise increases energy expenditure,
and as long as there are no compensatory changes in energy intake, this generates an energy
deficit. The accumulated net product, over a long-term period from an exercise-induced energy
deficit, leads to reductions in adipose tissue mass. Exercise induces specific morphological
adaptions in WAT, in regulating fat mass. It is believed that these exercise-induced adaptations
in adipose tissue phenotype during weight loss are partially explained by a decrease in adipocyte
size and lipid content. Indeed, this was demonstrated in two separate studies by Despres et al.
Using a 20-week endurance training program. A significant reduction in the diameter of
adipocytes and in fat cell weight, subsequent to a loss in body mass, was reported at the end of
the training period15.
The decrease in adipose tissue mass is also associated with a reduction in the production
and release of inflammatory adipokines in WAT. WAT is a target tissue for the anti-
inflammatory effects of exercise, specifically in obese individuals. For example, 6-weeks of
exercise training reduced the expression of TNF-alpha and MCP-1 in diet-induced obese (DIO)
mice, when compared to their lean counterparts. A similar observation was reported in obese

35. 35
humans, where 15-weeks of daily exercise reduced markers of inflammation in adipose tissue,
such as the expression of IL-6 and TNF-alpha. Taken together, this highlights the importance of
exercise as a therapeutic tool in preventing adiposity and adipose-tissue inflammation15.
Skeletal Muscle Metabolic Adaptations with Acute Exercise
Exercise (muscle contraction) improves the metabolic regulation of glucose via two
separate pathways: exercise/contractions and insulin. The following sections will discuss how
exercise increases muscle glucose uptake during exercise (insulin independent) and enhances
muscle insulin sensitivity post exercise (insulin dependent)15.
Skeletal Muscle Glucose Uptake During Exercise
Exercise requires an increase in glucose uptake by skeletal muscle in order to provide
substrate for energy production. This insulin independent process is facilitated by an acute
increase in glucose transport activity. Briefly, during muscle contractions, GLUT 4 translocates
to the cell surface from intracellular storage depots, in order to mediate glucose delivery to the
exercising muscle. However, the glucose transport process reverses rapidly upon cessation of
exercise.
As mentioned, the mechanism mediating this effect is distinct from the pathway used by
insulin. In support of this, wortmannin, an inhibitor of PI3-kinase, does not attenuate contraction
stimulated glucose uptake. Although the precise mechanisms involved in regulating contraction
stimulated glucose uptake have not been clearly defined, there is evidence to suggest that the
energy sensing enzyme 5’-AMP-activated protein kinase (AMPK) is involved. AMPK is
activated by increases in the AMP to ATP ratio and various knockout mouse models have
reported reductions in contraction/exercise stimulated glucose uptake in mice lacking AMPK15.
Post-Exercise Skeletal Muscle Insulin Sensitivity
Following exercise, glucose transporter levels at the membrane return to resting levels. As
the residual effects of the bout of exercise on insulin independent glucose uptake subside, there is
a marked increase in muscle insulin sensitivity that can persist upwards to 48 hours .The
sensitivity of the response to insulin has been previously defined as the concentration of insulin
to induce 50% of its maximal effect, whereas states of decreased sensitivity require a higher
concentration of insulin to produce the same effect. While the mechanisms that govern exercise
induced increases in insulin sensitivity remain unclear there is evidence to suggest that similar to
the regulation of contraction stimulated glucose uptake, that AMPK is involved in this process15.

36. 36
8.MECHANISM/PATHOPHYSIOLOGY OF EXERCISES HELPING IN BURNING FAT
Exercise, as a stressor, can cause complex stress effects in the body. It affects the
composition, structure and metabolic changes of human body through a series of complex
processes. Proper exercise can reduce the accumulation of fat in obese patients and achieve the
purpose of weight loss. At the same time, exercise can enhance physical fitness, promote health,
so that the incidence of chronic diseases closely related to obesity is greatly reduced. This health
promoting effect is not what other weight loss methods do. The movement is different from the
treatment of obesity and prevention, not only need to consume excess energy, the more important
is the need to ensure the highest proportion of fat oxidation and energy movement, the movement
in which material for energy.
Studies have shown that exercise can change the composition of fatty acids. Long term
exercise can increase the proportion of unsaturated fatty acids (especially n-6 polyunsaturated
fatty acids) in blood, and reduce the proportion of monounsaturated fatty acids. The change of
fatty acid composition is closely related to exercise intensity and mode of exercise. Relevant
studies have confirmed that the implementation of aerobic exercise intervention, obesity patient
lipid metabolism, insulin resistance, etc., can be improved to varying degrees.
However, there is no report on the selective use of fatty acids by skeletal muscle during
aerobic exercise. Different types of fatty acids of different diseases affect the degree of dietary
fatty acid intake balance is also a research hotspot. The possible mechanism but the different
parts of the present weight loss difference has no systematic study, the reason is: there is little
research system for exercise; rarely have a certain scale of exercise team and the mechanism of
physical exercise to lose weight; the weight loss process in different parts of the fat there is little
research use position difference; however, the effect of exercise to lose weight position
difference, in this regard, many people do not know the existence of this phenomenon. Because
of the effect of exercise to lose weight position difference, urgent need to find solutions to body
fat during exercise to lose weight drop method and the way of location difference, in order to
improve the shape of the body of obese patients, improve the effect of exercise to lose weight33.

37. 37
9.FAT METABOLISM
It has been known for some time that the regulation of adipose tissue lipolysis and the
release of FFAs from adipose tissue and ultimate delivery to the muscle and the entry of fat into
the mitochondria were important sites of control for fat oxidation. However, it is now understood
that the regulation of fat metabolism and oxidation in skeletal muscle is as complex as
carbohydrate metabolism and involves multiple regulatory sites, including (1) FFA transport
across the muscle membrane with protein carriers; (2) binding and transport of FFAs in the
cytoplasm; (3) IMTG synthesis; (4) IMTG degradation; (4) FFA transport across the
mitochondrial membranes with the CPT complex and additional protein facilitators; (5) potential
regulation within the b-oxidation pathway; and (6) the overarching aspect of the regulation of
skeletal muscle fat oxidation—that the mitochondrial volume (the total amount of fat transport
and metabolizing proteins) determines the overall capacity to oxidize fat34.
There is also regulation in the tricarboxylic cycle and the electron transport chain that is
common to both carbohydrate and fat34.
Fat oxidation increases from rest to low- and moderate intensity exercise (maximum at
*60–65 % VO2max), but decreases at power outputs above approximately 75 % VO2max.
Increasing the exercise power output above approximately 50 % VO2max also increases the use
of muscle glycogen. Blood glucose levels and muscle glycogenolysis, glycolytic flux, PDH
activation, and carbohydrate oxidation are all increased during exercise at higher, compared with
moderate, exercise power outputs34 .

38. 38
10. EXERCISE PRESCRIPTION AND PROGRAMES FOR OBESITY
The exercise prescription involves four basic factors:
1. Exercise Mode
2. Exercise Frequency
3. Exercise Duration
4. Exercise Intensity
Exercise Mode
The prescribed exercise program should focus on one or more modes, or types, of
cardiovascular endurance activities. Traditionally, the activities prescribed most frequently are:
• walking,
• jogging,
• running,
• hiking,
• cycling,
• rowing, and
• swimming.
Because these activities do not appeal to everyone, alternative activities have been
identified that promote similar cardiovascular endurance gains. Spinning, aerobic dance, box or
bench stepping, and most racket sports also have been shown to improve aerobic capacity31. This
helps in weight loss in obesity.
Exercise Frequency
The frequency of exercise participation, although certainly an important factor to
consider, is probably less critical than either exercise duration or intensity. Research studies
conducted on exercise frequency show that three to five days per week is an optimal frequency.
This does not mean that six or seven days per week won’t give additional benefits; but simply for
the health-related benefits, the optimal gain is achieved with a time investment of three to five
days per week. Exercise initially should be limited to three or four days per week and increased
up to five or more days per week only if the activity is enjoyed and physically tolerated31. For
obesity weight loss 4 to 5 days per week.
Exercise Duration
Several studies have demonstrated improvement in cardiovascular conditioning with
endurance exercise periods as brief as 5 to 10 min per day. More recent research has indicated
that 20 to 30 min per day is an optimal amount. Improvements in aerobic capacity are gained
with either a short-duration, high-intensity program or a long-duration, low-intensity program if
the minimal threshold is exceeded for both duration and intensity. Similar benefits are also
gained whether the daily endurance training session is conducted in multiple shorter bouts (e.g.,
three 10 min bouts) or a single long one (e.g., a single 30 min bout). Obviously, longer bouts will
facilitate weight loss31.

39. 39
Exercise Intensity
The intensity of the exercise bout appears to be the most important factor. How hard must
people push themselves to gain benefits? Evidence now suggests that a modest training effect
can be accomplished in some people through training at intensities of 40% or less of their aerobic
capacities and possibly could lead to health benefits. For most, however, the appropriate
minimum intensity appears to be at least 50% to 60% VO2max. An upper level for intensity will
depend on the purpose for training. Obviously, training for competition requires high intensity.
However, training for purposes of attaining and maintaining optimal health would seldom exceed
80% VO2max. A series of recent studies from McMaster University in Hamilton, Ontario
(Canada), has clearly demonstrated that very high intensity, low-volume interval training can
markedly increase aerobic capacity. Substantial increases in muscle oxidative capacity and
endurance performance have been obtained in a training period as short as two weeks31. In
obesity 60% to 80% intensity training is done for weight loss.
Resistance Training (RT)
The RT group participants used weight-training equipment at 60–70% of one repetition
maximum with a qualified professional trainer. They were trained two times a week for
8 weeks. Mainly the large systemic muscle groups were targeted, and the following 10 exercises
were incorporated in the training design: shoulder presses, bicep curls, triceps curls, bench
presses, deadlifts, leg swings, squats, standing rows, unilateral rows, and split front squats.
Progressive resistance load training was used, in which the difficulty of the exercise was adjusted
every 2 weeks in ascending order from simple to difficult. The participants performed three
sets of 8–12 repetitions with a 2–3 minute rest between sets. The total training time was 60
minutes with 48-hour interval for each training session. The RT performance followed the
guidelines recommended by the American College of Sports Medicine.15 after each completion
of the training program, the participants’ rate of perceived exertion 16 of the session was
immediately recorded on a scale from 0–1035.
Aerobics Training (AT)
The AT group engaged in moderately intense AT in two 60-minute sessions per week for
a total of 8 weeks. The session consisted of 5–10 minutes of dynamic stretching and warm up
and 40–45 minutes of the actual training. The class comprised a combination of dance steps such
as stepping on the spot, knee lifts, high knee running, rowing arm swings, arm swings, twist
steps, arm raises, squats, V steps, mambo steps, diamond steps, and point step jumps. In addition,
10 minutes of closing and relaxation exercises were included25.
Combine Training (CT)
The CT group engaged in identical, but separate, RT and AT with a qualified professional
trainer. For a total of 8 weeks, they performed each training mode once a week with the AT
following 48 hours after the RT35.
Control Group (CON)
The CON group simply maintained their day-to-day lifestyles and dietary habits and was
prohibited from engaging in any exercises35.

40. 40
Exercise Recommandation For Adults32
Recommendations for the components of a complete exercise program include the
following (note – deconditioned or sedentary individuals may benefit from activity levels below
those listed; additional recommendations are available for youth as well as older adults (1)):
Aerobic Exercise: At least 5 days/week of moderate intensity activity or at least 3
days/week of vigorous activity, or a combination of moderate and vigorous on at least 3 to 5
days/week; 30 to 60 minutes/day for moderateactivityand20to60minutes/day for vigorous
activity; includes exercises using major muscle groups in a continuous, rhythmic manner.
Resistance Exercise: Train each major muscle group 2 to 3 days per week; for strength
development 60% to 70% of one repetition max (1-RM) for novice to intermediate exercisers
and higher levels (80% or greater) for more experienced strength exercisers, for muscular
endurance development 50% 1-RM or lower; includes exercises for each major muscle group.
Flexibility Exercise: At least 2 to 3 days / week (daily is most effective);stretch to point
of feeling tightness or slight discomfort; includes exercises (static, dynamic, ballistic, or
proprioception neuromuscular facilitation) for each of the major muscle-tendon units.
Neuromotor Exercise: At least 2 to 3 days / week; consider at least 20 to 30 minutes;
activities depend on the individual with recommendations for fall reduction including exercises
involving balance, agility, coordination, gait, proprioception, and other multifaceted activities
such as Tai Chi and yoga.
ACSM’s Guidelines for Exercise Testing and Prescription, 10th edition, includes
information on the principle of progression as follows32:
Aerobic Exercise: Program advancement can occur by adjusting frequency, intensity, and /or
time, thus progressing the overall exercise volume. Care should be taken to enhance adherence
also while reducing risks of injury or cardiac events; the recommendation of “start low and go
slow” reflects this objective.
Resistance Exercise: Program advancement can occur by adjusting resistance, repetitions, and /or
frequency.
Flexibility Exercise: Methods to achieve optimal progression are not known.
Neuromotor Exercise: Methods to achieve optimal progression are not known

41. 41
OBESITY EXERCISE PROGRAMES32,15,35:
Modes Goals Intensity/frequency/duration Time to goal
 Aerobic
Large muscle
activities
(walking,
rowing,
cycling, water
aerobics)
-Reduce weight
-Increase functional
performance
-Reduce risk of CAD
 50-70% VO2 peak
 Monitor RPE and HR
 5days/wk
 40-60 min/session(or 2
session/day of 20-30min)
 Emphasize duration rather
than intensity
-9-12min
-Increase duration
over intensity
 Flexibility
Stretching
-Increase ROM  Daily or at least 5 session/wk -15mins
 Functional
activity-specific
exercise
-Increase ease of
performing ADLs
-Increase vocational
potential
-Increase physical
self-confidence
 Resistance
training
(isometric,
concentric ,
eccentric
exercise)
 Reduce
weight
 Increasing/
maintaining
muscular
strength with
aging .
 preserving
bone mineral
density.
 Three sets of 8–12
repetitions with a 2–3
minute rest between sets.
 60min/session/day
 3days/wk
-10-15min
 Combine
Aerobic
and
Resistance
exercise
 Reduce
weight
 Cardio fitness
 45mins session
 8weeks 48hours
-12mins

42. 42
11.OBESITY: EXERCISE TESTING32:
Methods Measures Endpoints Comments
Aerobic
 Cycle
(ramp protocol 17
watts/min; staged
protocol 25-50
watts/ 3-min stage)
 Treadmill
(1-2 METs/3-min
stage)
 12-lead ECG,
HR
 BP, rate pressure
product
 RPE (6-20)
 Serious
dysrhythmias
 >2mm ST-segment
depression or
elevation
 Ischaemic threshold
 T- wave inversion
with significant ST
change
 SBP>250mmHg or
DBP>115mmHg
 Voliational fatigue
 Clients are at higher
than normal risk for
CAD/Hypertension
Flexibility
Goniometry
 ROM  Used to determine
joints that need
stretching.
Neuromuscular
Gait analysis
Balance
 Useful in
identifying
individual with
poor balance who
may require more
supervision during
exercises and to
ascess
improvement in
balance after
training and/or
weight reduction.

43. 43
12.EFFECTS OF EXERCISE
Aerobics exercise
 Low-intensity aerobic exercise burns no more fat than more vigorous exercise, and more
total calories are spent in a more strenuous workout.
The higher the exercise intensity, the greater the body’s reliance on carbohydrate as an
energy source. With high-intensity aerobic exercise, carbohydrate can supply up to 90% or more
of the body’s energy needs. During the late 1980s, various professional exercise groups
promoted low intensity aerobic exercise to increase the loss of body fat. These groups theorized
that low-intensity aerobic training would allow the body to use more fat as the energy source,
hastening the loss of body fat. Indeed, the body uses a higher percentage of fat for energy at
lower exercise intensities. However, the total calories expended does not necessarily change as a
result of the body’s use of fat31.
 Vigorous activity and longer duration are preferable to the extent of one’s capabilities
because they are most clearly associated with better health and longer life.
Vigorous-intensity exercise seems to provide the best benefits. As compared with prolonged
moderate intensity activity, vigorous-intensity exercise has been shown to provide the best
improvements in aerobic capacity, coronary heart disease risk reduction, and overall
cardiovascular health30.
 Moderate-intensity exercise does provide substantial health benefits, research data also
show a dose-response relationship between physical activity and health. That is, greater
health and fitness benefits occur at higher duration and/or intensity of physical activity30.
 Indicated that both Aerobic training (AT) and Resistance training (RT) can effectively
improve obesity factors. Previous studies have attested that AT exhibits a favorable effect
on reducing obesity risk factors, whereas RT has resulted in increasing muscle mass and
strength35.

44. 44
Resistance exercise:
Resistance exercise training and isometric exercises are important and sometimes
overlooked aspects of an Exercise Training program that have many health benefits including
increasing / maintaining muscular strength with aging (prevention of sarcopenia) and preserving
bone mineral density. Although, resistance training alone contributes to the reduction of body fat,
the effect on overall weight loss is minimal. Little evidence exists that resistance training alone
promotes weight loss36.
Weight loss exercise
Through exercise, children's body weight, fat weight, BMI, rate system, thigh
circumference, waist circumference, hip circumference, thigh circumference, waist hip ratio,
height than hip height ratio than the phase weight before decreased, can improve the body shape
of young children. With the continuous development of society, advanced science and
technology will be liberated people from the troubles of physical activity, more food filling , the
prevalence rate of hypertension is also showing a rising trend. The individual characteristics of
sports must be suitable for patients, such as the choice of jogging, brisk walking, recreational
sports, aerobics and sports can maintain a longer period of time.
The right sport must first be of interest, avoid sports boredom and become negative
factors to lose weight; exercise intensity should not be too large, such as fast running, fast
swimming, ball games prone to fatigue. The sports exercise intensity is too large, the duration of
obesity patients can adhere to the short, exercise time because of the limited body and not good
use of fat for energy: first, exercise intensity is too large is not conducive to the sports
consumption of fat in the body, and exercise time to consume more glycogen in experience the
metabolism of blood glucose decline, increased appetite. The accumulation of lactic acid in the
body is also not conducive to the oxidation of fat decomposition; second, for obese patients,
exercise intensity is too large, there may be some security risks, easy to cause sports injuries.
Exercise intensity exercise is not suitable for small weight, strength is too small to achieve the
movement of the heart rate for the fat burning rate target, cannot produce a certain degree of
stimulation on the body, it is impossible to achieve the desired therapeutic effect.
Therefore, obese patients should choose the dynamic and rhythmic exercise that the large
muscle groups participate in. Studies have shown that the combination of different sports can
eliminate the boredom of the participants. Therefore, in the process of sports treatment of
obesity, choose a variety of sports items match, can improve obesity patients participate in
exercise to reduce weight of enthusiasm. If you can choose brisk walking and swimming: quick
walk to the swimming pool, also equivalent to complete part of the preparatory activities and
finishing activities33.
Exercise intensity is mostly expressed by heart rate, percentage of maximal heart rate and
percentage of maximal oxygen uptake. In the treatment of obesity, it is generally believed that its
intensity is 60%-80% of the maximum heart rate, and when the maximal oxygen uptake is 50%-
70%, the ideal weight loss effect can be achieved. Because of the range of motion intensity, the
rate of lipid oxidation is in the most ideal state. Because of the quiet heart rate also affects the

45. 45
rate of fat oxidation, so only through the heart rate and maximal exercise intensity to determine
the oxygen content is not scientific, ignoring the impact of heart rate on lipid oxidation rate may
be determined from the objective exercise intensity. Diet control in exercise weight loss is a
scientific behavior. It is different from dieting alone. The only way to lose weight is to lower
energy intake than energy consumption, and to control energy intake. In the exercise of weight
loss, the basis for the control of diet is energy consumption is greater than energy intake,
focusing on increasing energy consumption. Exercise combined with proper diet control is an
ideal way to treat obesity. It can achieve satisfactory weight loss effect, and also has obvious
promoting effect on health. Exercise treatment of obesity principle is to increase the body's
energy consumption by exercise, the body will be redundant fat consumption, and then achieve
the purpose of weight loss. Exercise to maintain good eating habits, diet control limits of total
calories, diet control should be gradual and moderate as appropriate, to ensure a balanced
nutrition, cannot be expanded to all nutrient limitation.
Therefore, diet control must also ensure that there is a normal amount of high quality
food protein supply in order to maintain normal nitrogen balance during the weight loss period,
but the food protein supply should not be too much. Strict control of fat intake, carbohydrate
intake should be accounted for 40%-55% of the total daily calories, and ensure adequate and
balanced diet of vitamins and inorganic salt supply33.

46. 46
13.TYPES OF PHYSICAL FITNESS30.
Physical fitness is classified into health-related and skill-related.
Health-related fitness relates to the ability to perform activities of daily living without
undue fatigue and is conducive to a low risk of premature hypokinetic diseases. The health-
related fitness components are cardiorespiratory (aerobic) endurance, muscular strength and
endurance, muscular flexibility, and body composition.
Skill-related fitness components consist of agility, speed, balance, coordination, reaction
time, speed, and power. These components are related primarily to successful sports and motor
skill performance. Participating in skill-related activities contributes to physical fitness, but in
terms of general health promotion and wellness, the main emphasis of physical fitness programs
should be on the health-related components.

47. 47
14.RECOMMENDED WEIGHT LOSS PROGRAMS37
 Healthy life style such as Regular exercise, yoga, meditation, food consumption.
 Balanced diet practice.
 Reduce day today stress.
 Avoid of junk foods, fast foods.
 Aerobics exercises.
 Physical activity at least 30min per day.
 Understanding drug dosage and its consequences intimation.
 Hydro therapy: sufficient intake of water.
 Proper sleeping practices such at least 6-7hours sleep required for adult per day.
 Benefits of regular Sports activities31.
 Avoid overeating to prevent overweight and obesity.
 Very-Low-Calorie and Low-Calorie Programs.

48. 48
15.SUPPLEMENTS:
 Role of serotonin
Serotonin has been implicated in promoting self-control, regulation of hunger and
physiological homeostasis, and regulation of caloric intake38.
Serotonin (5-hydroxytryptamine, 5-HT) is a highly conserved biogenic amine that resides in
nonneuronal and neuronal tissues that are specifically regulated via tryptophan hydroxylase 1
(Tph1) and Tph2, respectively. Recent findings suggest that increased peripheral serotonin and
polymorphisms in TPH1 are associated with obesity; however, whether this is directly related to
reduced BAT thermogenesis and obesity is not known. The inhibitory effects of serotonin on
energy expenditure are cell autonomous, as serotonin blunts adrenergic induction of the
thermogenic program in brown and beige adipocytes in vitro. As obesity increases peripheral
serotonin, the inhibition of serotonin signaling or its synthesis in adipose tissue may be an
effective treatment for obesity and its comorbidities39.
Genetic or chemical inhibition of Tph1 protects or reverses the development of HFD-induced
obesity and dysglycemia via activation of UCP1-mediated thermogenesis. Although several
metabolites may induce adaptive thermogenesis in adipose tissue and attenuate obesity, such as
retinaldehyde, β-aminoisobutyric acid or locally released catecholamines, to our knowledge,
serotonin is the first metabolite shown to be elevated in obesity that inhibits the activity of BAT
or beige adipose tissue in mammals. Thus, inhibiting Tph1-derived serotonin may be effective in
reversing obesity39.
 Role of Fiber supplements
A high level of dietary fiber consumption (eg, replacement) has been associated with a 30%
reduction in the risk of gaining weight or developing obesity40.
A yearlong study in 97 adolescents has been quoted as demonstrating weight loss for a
‘‘prebiotic’’ fiber supplement (soluble, nonviscous, fermentable), but a closer look at the data
shows that the prebiotic fiber group (8 g/d) was not different from baseline for body mass
index.46 In contrast, gel-forming fibers (eg, guar gum, pectin, and psyllium) have been shown to
increase satiety and reduce subsequent energy intake.47Y49 A well cited clinical study
demonstrated that apples were significantly more satiating than fiber free apple juice, even
though the juice provided the same level of carbohydrate as the apples.50 Pectin is the gel-
forming fiber in apples and has been shown to increase satiety40.
Gel-forming fibers may influence satiety by several mechanisms, including delayed
degradation and absorption of nutrients in the small bowel, leading to a ‘‘sustained’’ delivery of
nutrients, and delivery of nutrients to the distal ileum with subsequent stimulation of feedback
mechanism like the ‘‘ileal brake’’ phenomenon (slows gastric emptying and small bowel transit)
and decreased appetite. Studies have used an insoluble fiber or a soluble nonviscous fiber as a
negative control, reinforcing the assertion that the effect on satiety is a gel-dependent

49. 49
phenomenon. Satiety is often assessed in short-term clinical studies as a tool or mechanism for
predicting the potential for decreased energy intake and weight loss, but the end therapeutic goal
is weight loss40.
Fiber supplement intake ranged from 4.5 to 20 g/d, and the results showed that only 1 of 17
studies provided evidence of weight loss greater than placebo40.
 Role of protein supplements
High protein intake (>1.0 g/kg/d), particularly consumption of leucine-rich proteins such as
whey protein, is recommended to prevent age-associated muscle loss and to mitigate the adverse
effect of diet-induced weight loss on muscle mass because protein ingestion stimulates muscle
protein synthesis in a dose-dependent manner, leucine ingestion augments the anabolic effect of
protein consumption , and high protein intake blunts the weight-loss-induced decline in lean
body mass . However, it is not known whether high protein intake during weight loss actually
prevents the loss of skeletal muscle because (1) the acute effect of protein ingestion on muscle
protein synthesis might not predict the chronic effect of protein ingestion on muscle mass, which
is determined by the balance between synthesis and breakdown; and (2) the weight-loss-induced
change in lean body mass (determined by using dual-energy x-ray absorptiometry [DXA]) is not
a reliable surrogate for changes in muscle mass (determined by using computed tomography or
magnetic resonance imaging [MRI])41 .
High protein intake during weight-loss therapy is often recommended to facilitate both
short-term and long-term weight loss because protein increases satiety and the thermogenic
effect of feeding41.
 Role of caffeine supplements
Caffeine intake to improve lipid metabolism in obesity should be carefully controlled with
relevance to defective caffeine metabolism in obese individuals with NAFLD. Defective caffeine
metabolism in obese individuals can allow excessive caffeine transport to the central nervous
system with effects on appetite regulation and induction of Type 3 diabetes. Connections
between LPS and magnesium deficiency may override the beneficial effects of caffeine on the
maintenance of the adipocyte-liver crosstalk important to the prevention of NAFLD in obesity42.
 Green coffee
The mechanisms proposed for the effects of green coffee extract on weight loss include a
lipolytic effect on adipocytes as well as a decrease in pancreatic lipase activity inhibition of fatty
acid synthase, hydroxymethylglutaryl-CoA reductase, and acyl-CoAcholesterol acyltransferase;
an increase in β-oxidation; and promotion of PPAR-α expression in the liver.
A meta-analysis reported a statistically significant weight loss of almost 2.5 kg after
supplementation with green coffee extract in doses ranging from 180 to 200 mg/day over a
treatment period of 4 to 12 weeks43.

50. 50
 White Kidney Bean
Phaseolus vulgaris extract is marketed as an OTC dietary supplement for weight loss because
of its so-called “carbohydrate blocker” actions, which refers to the fact that phaseolamin inhibits
pancreatic amylase and thus digestion of dietary starches. Effects from dosages ranging from 1.5
to 6 g/day were proven only in relatively small, short-term studies. For example, a clinical trial
including 60 overweight subjects reported greater reductions in body weight, fat mass, and waist,
hip, and thigh circumference in those taking white kidney bean extract versus the placebo
group43.
 Bitter Orange
Also known as Citrus aurantium, Seville orange, or sour orange, bitter orange has been used
in traditional Chinese as well as South American folk medicine for a variety of conditions . Its
extracts have been used as supplements to treat obesity and to enhance exercise performance. It
contains multiple phytochemicals, including octopamine, as well as alkaloids, particularly
synephrine. These alkaloids may exert sympathomimetic effects that contribute to an oxidative
metabolism—for example, by promoting lipolysis and stimulating β3- and α-adrenergic
receptors, as well as by inhibiting cyclic adenosine monophosphate (cAMP) production43.

51. 51
REVIEW OF LITERATURE
1. Obesity : pathophysiology and management.1 (2018) , conducted a study on Obesity
continues to be among the top health concern across the globe, the aim of this study is to
understand the pathophysiology of obesity and how excess adiposity leads to type 2
diabetes, hypertension and cardiovascular diseases. Lifestyle modification recommended
as cornerstone for the obesity management but there were no long lasting benefits. Than
5 drugs therapies-orlistat, lorcaserin, liraglutide, phentermine/tropiramate,
naltrexone,/bupropionfor for long term obesity management . They concluded as several
medical devices are available for long term and short term management; bariatric surgery
recommended for type 2 diabetes resolutions.
2. Dairy and Exercise as a Novel Treatment Strategy for Obesity.15 (2017), conducted
study on investigation was to compare the individual and combined effects of dairy and
endurance exercise training in reducing weight gain and adiposity in a rodent model of
diet-induced obesity. A 6-week feeding intervention of a high fat, high sugar diet was
used to rapidly induce obesity in male Sprague Dawley rats (6-weeks of age). Rats were
then assigned to one of four weight-matched groups for 6 weeks: 1) casein-sedentary 2)
casein-exercise 3) dairy sedentary 4) dairy-exercise. The exercise training intervention
took place 5 days/week (60 minutes of treadmill running: 20m/min, 10% incline). The
effects of exercise training in combination with dairy protein were greater than either
intervention alone in attenuating increases in weight gain. They concluded that dairy
protein attenuated weight gain in obese rats to a similar extent as exercise training, and
appeared to exert a partial additive effect when combined with exercise. While exercise
training reduces weight gain through increases in energy expenditure with each bout of
exercise, dairy would appear to increase the amount of lipid excreted in the feces.
3. An Optimization Method for Weight Loss Training Mode based on Exercise and
Diet Intervention33.(2017), conducted a study on weight loss training mode based on
exercise and diet intervention. They concluded that exercise training combined with
dietary intervention can improve the physical fitness index of obese college students, and
the improvement of endurance items is more obvious. At the same time, a single dietary
intervention had no significant effect on the body circumference index of subjects. At the
same time, exercise also need to ensure the highest proportion of fat oxidation and energy
consumption, pay attention to nutrition collocation and avoid excessive exercise
4. Serotonin enhances the impact of health information on food choice.38 (2017),
conducted a study on Serotonin has been implicated in promoting self-control, regulation
of hunger and physiological homeostasis, and regulation of caloric intake. They
investigated the effects of an acute dose of the serotonin reuptake inhibitor citalopram on
choices between food items that differed along taste and health attributes, compared with
placebo and the noradrenaline reuptake inhibitor atomoxetine. Twenty-seven participants
attended three sessions and received single doses of atomoxetine, citalopram, and placebo

52. 52
in a double-blind randomised cross-over design. Relative to placebo, citalopram
increased choices of more healthy foods over less healthy foods. Citalopram also
increased the emphasis on health considerations in decisions. Atomoxetine did not affect
decision making relative to placebo. The results support the hypothesis that serotonin
may influence food choice by enhancing a focus on long-term goals. They concluded that
the findings are relevant for understanding decisions about food consumption and also for
treating health conditions such as eating disorders and obesity.
5. Effects of Different Types of Exercise on Body Composition, Muscle Strength, and
IGF-1 in the Elderly with Sarcopenic.35 (2017), conducted a study to investigate the
influence of resistance training (RT), aerobic training (AT), or combination training (CT)
interventions on the body composition, muscle strength performance, and insulin-like
growth factor 1 (IGF-1) of patients with sarcopenic obesity. Sixty men and women aged
65–75 with sarcopenic obesity. Participants were randomly assigned to RT, AT, CT, and
control (CON) groups. After training twice a week for 8 weeks, the participants in each
group ceased training for 4 weeks before being examined for the retention effects of the
training interventions. The body composition, grip strength, maximum back extensor
strength, maximum knee extensor muscle strength, and blood IGF-1 concentration were
measured. The skeletal muscle mass (SMM), body fat mass, appendicular SMM/weight
%, and visceral fat area (VFA) of the RT, AT, and CT groups were significantly superior
to those of the CON group at both week 8 and week 12. They concluded older adults
with sarcopenic obesity who engaged in the RT, AT, and CT interventions demonstrated
increased muscle mass and reduced total fat mass and VFA compared with those without
training. The muscle strength performance and serum IGF-1 level in trained groups,
especially in the RT group, were superior to the control group.
6. Effects of two-months balanced diet in metabolically healthy obesity: lipid
correlations with gender and BMI-related differences.7 (2015) ,conducted a study was
to assessed gender and BMI-related difference in FA, estimated desaturase activities and
the efficacy on metabolic changes produced by 2-months well-balance diet in MHO
subjects. In 103 MHO subjects (male=30 and female=73 age:42.2±9.5) FA, estimated
desaturase activity, body composition (by DXA), Body Mass Index (BMI), lipid profile,
adipokines, insulin resistance , C-reactive protein, Atherogenic index of plasma (AIP)
and Body Shape Index (ABSI) have been assessed. Gender and BMI related difference
have been evaluated and the efficacy produced by 2-months well-balance diet has been
considered. At baseline, obese subjects, compared to overweight. Gender and BMI
related difference have been evaluated and the efficacy produced by 2-months well-
balance diet has been considered. The conclusion of this study is diet intervention was
effective in improving metabolic indices.
7. Role of Leptin in Obesity.13 (2015), conducted a study on Obesity has been the problem
in the societies of developing and developed world. Some diseases caused by obesity. To
overcome of those diseases it is necessary to control obesity. The Leptin may be a vital
tool to fight against obesity because it is the anti-obesity hormone. They concluded by

53. 53
using leptin therapy may be possible to prevent obesity and diseases like hypertension
and diabetes mellitus before their occurrence.
8. Effect of Reducing Portion Size at a Compulsory Meal on Later Energy Intake, Gut
Hormones, and Appetite in Overweight Adults.25 (2015), conducted a study
investigated the impact of reducing breakfast PS on subsequent EI, postprandial
gastrointestinal hormone responses, and appetite ratings. In a randomized crossover
design (n533 adults; mean BMI 29 kg/m2), a compulsory breakfast was based on 25% of
gender-specific estimated daily energy requirements; PS was reduced by 20% and 40%.
EI was measured at an ad libitum lunch (240 min) and snack (360 min) and by weighed
diet diaries until bed. Blood was sampled until lunch in 20 participants. Appetite ratings
were measured using visual analogue scales. EI at lunch and over the whole day except
breakfast did not differ. Appetite ratings profiles, but not hormone concentrations, were
associated with subsequent EI. They concluded smaller portions at breakfast led to
reductions in gastrointestinal hormone secretion but did not affect subsequent energy
intake, suggesting small reductions in portion size may be a useful strategy to constrain
EI.
9. Calorie for calorie, dietary fat restriction results in more body fat loss than
carbohydrate restriction with people with obesity.29 (2015) , conducted a study on
Dietary carbohydrate restriction has been purported to cause endocrine adaptation that
promote body fat loss more than dietary fat restriction. They selectively restricted dietary
carbohydrate versus fat for 6 days following 5 days baseline diet in 19 adults with obesity
confined to metabolic ward where they exercise daily. Subject received both isocaloric
diets in random order during each of 2 inpatient stays. Body fat loss was calculated as
difference between daily fat intake and net fat oxidation measured while residing in
metabolic chamber. Whereas carbohydrate restriction led to sustained increased in fat
oxidation and loss of 53±6 g/day of body fat, fat oxidation was unchanged by fat
restriction , leading to 89±6 g/day of fat loss, and significantly greater than carbohydrate
restriction. They concluded Body act to minimize body fat differences with prolonged
isocaloric diets varying in carbohydrate and fat.
10. The Role of Exercise and Physical Activity in Weight Loss and
Maintenance36.(2015), conducted a study on the role of physical activity (PA) and
exercise training (ET) in the prevention of weight gain, initial weight loss, weight
maintenance, and the obesity paradox. In particular, we will focus the discussion on the
expected initial weight loss from different ET programs, and explore intensity/volume
relationships. Based on the present literature, unless the overall volume of aerobic ET is
very high, clinically significant weight loss is unlikely to occur. Also, ET also has an
important role in weight regain after initial weight loss. Overall, aerobic ET programs
consistent with public health recommendations may promote up to modest weight loss
(~2 kg), however the weight loss on an individual level is highly heterogeneous. They
concluded Clinicians should educate their patients on reasonable expectations of weight
loss based on their physical activity program and emphasize that numerous health

54. 54
benefits occur from PA programs in the absence of weight loss.
11. Evidence-Based Approach to Fiber Supplements and Clinically Meaningful Health
Benefits, Part 2.40 (2015), conducted a study on Dietary fiber that is intrinsic and intact
in fiber-rich foods is widely recognized to have beneficial effects on health when
consumed at recommended levels (25 g/d for adult women, 38 g/d for adult men). Fiber
supplements cannot be presumed to provide the health benefits that are associated with
dietary fiber from whole foods. In this study they focus on the effects of fiber
supplements in the large bowel, including the 2 mechanisms by which fiber
prevents/relive constipation the gel-dependent mechanism for attenuating diarrhea and
normalizing stool form in irritable bowel syndrome, and the combined large bowel/small
bowel fiber effects for weight loss/maintenance. They concluded how processing for
marketed products can attenuate efficacy, why fiber supplements can cause
gastrointestinal symptoms, and how to avoid symptoms for better long-term compliance.
12. New Insights into the Interaction of Carbohydrate and Fat Metabolism during
Exercise.34 (2014), conducted a study on Fat and carbohydrate are important fuels for
aerobic exercise and there can be reciprocal shifts in the proportions of carbohydrate and
fat that are oxidized. The availability of substrate, both from inside and outside of the
muscle, and exercise intensity and duration will affect these environments. The regulation
of fat metabolism is complex and involves many sites of control, including the transport
of fat into the muscle cell, the binding and transport of fat in the cytoplasm, the regulation
of intramuscular triacylglycerol synthesis and breakdown, and the transport of fat into the
mitochondria. The discovery of proteins that assist in transporting fat across the plasma
and mitochondrial membranes, the ability of these proteins to translocate to the
membranes during exercise, and the new roles of adipose triglyceride lipase and
hormone-sensitive lipase in regulating skeletal muscle lipolysis are examples of recent
discoveries. They concluded that this information has led to the proposal of mechanisms
to explain the down regulation of fat metabolism that occurs in the face of increasing
carbohydrate availability and when moving from moderate to intense aerobic exercise.
13. A link between FTO, ghrelin, and impaired brain food-cue responsivity.12 (2013) ,
conducted a study on Polymorphisms in the fat mass and obesity-associated gene (FTO)
are associated with human obesity and obesity-prone behaviors, including increased food
intake and a preference for energy-dense foods. Using functional MRI (fMRI) in normal-
weight AA and TT humans, they found that the FTO genotype modulates the neural
responses to food images in homeostatic and brain reward regions. Furthermore, AA and
TT subjects exhibited divergent neural responsiveness to circulating acyl-ghrelin within
brain regions that regulate appetite, reward processing, and incentive motivation. In cell
models, FTO overexpression reduced ghrelin mRNA N6-methyladenosine methylation,
concomitantly increasing ghrelin mRNA and peptide levels. Furthermore, peripheral
blood cells from AA human subjects exhibited increased FTO mRNA, reduced ghrelin
mRNA N6-methyladenosine methylation, and increased ghrelin mRNA abundance
compared with TT subjects. They concluded that their findings show that FTO regulates

55. 55
ghrelin, a key mediator of ingestive behavior, and offer insight into how FTO obesity-risk
alleles predispose to increased energy intake and obesity in humans.
14. Effect of Diet and Exercise, alone or Combined, on Weight and Body Composition
in Overweight-to-Obese Postmenopausal Women.9 (2012), conducted a study on
Lifestyle interventions for weight loss are the cornerstone of obesity therapy. A
postmenopausal woman is population with a high prevalence of obesity. They conducted
a, 4-arm randomized trial among 439 overweight-to-obese postmenopausal sedentary
women to determine the effects of a calorie-reduced, low-fat diet (D), a moderate
intensity, facility-based aerobic exercise program (E), or the combination of both
interventions (D+E), vs. a no-lifestyle change control (C) on change in body weight and
composition.. Participants were included with a mean age of 58.0 ± 5.0 years, a mean
BMI of 30.9 ± 4.0 kg/m2 and an average of 47.8 ± 4.4% body fat. Baseline and 12-month
weight and adiposity measures were obtained by staff blinded to participants’
intervention assignment. Three hundred and ninety nine women completed the trial (91%
retention). Using an intention-to-treat analysis, average weight loss at 12 months was
−8.5% for the D group, −2.4% for the E group and −10.8% for the D+E group whereas
the C group experienced a nonsignificant −0.8% decrease. They concluded BMI, waist
circumference, and % body fat were also similarly reduced. Among postmenopausal
women, lifestyle-change involving diet, exercise, or both combined over 1 year improves
body weight and adiposity, with the greatest change arising from the combined
intervention.
15. Long-term effectiveness of diet-plus-exercise interventions vs. diet-only
interventions for weight loss: a meta-analysis. 18 (2009), conducted a study on Diet and
exercise are two of the commonest strategies to reduce weight. The objective of this
study was to systemically review the effect of diet-plus-exercise interventions vs diet-
only interventions on both long-term and short-term weight loss. Studies were retrieved
by searching MEDLINE and Cochrane Library (1966 – June 2008). Studies were
included if they were randomized controlled trials comparing the effect of diet-plus-
exercise interventions vs. diet-only interventions on weight loss for a minimum of 6
months among obese or overweight adults. Eighteen studies met our inclusion criteria.
They concluded Diet-plus-exercise interventions provided significantly greater weight
loss than diet-only interventions.

56. 56
17.CONCLUSION
The conclusion of this study is, with sarcopenic obesity received resistance training,
aerobic training, or combine training demonstrated increased muscle mass and reduced total fat
mass and visceral fat area. Patients wishing to lose weight should participate in physical activity
and caloric restriction to improve the chances of weight loss. So only exercise is effective but
combines with diet and exercise is more effective in weight loss. In resistance training group
increase muscle strength performance and serum IGF-1 level. Exercise training, especially for
overweight and obese individuals at risk for CV diseases or with current CV conditions.

57. 57
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