|Year : 2015 | Volume
| Issue : 4 | Page : 166-171
Diet and exercise in obesity: A case report from India
Abel Samuel, Joy Bazroy, Anil Purty, Kisku King Herald, Zile Singh, Maghida Sridhar, Irusappan Srikanth
Department of Community Medicine, Pondicherry Institute of Medical Sciences, Pondicherry, India
|Date of Web Publication||19-Oct-2015|
Department of Community Medicine, Pondicherry Institute of Medical Sciences,Pondicherry
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Obesity is an excess of body fat, resulting in adverse health effects. Obesity has emerged as a major public health problem. A rural mother aged 58 years, a widow for the past 29 years, presented to the chest clinic with complaints of breathlessness, snoring, and excessive sleepiness. Diet and exercise along with counseling for a lifestyle change made her lose 7% of body weight. Obesity is a public health problem with multiple risk factors, and so its management is complex. This sheds light on a nonpharmacological approach for the management of obesity.
Keywords: Diet, exercise, management, obesity, rural
|How to cite this article:|
Samuel A, Bazroy J, Purty A, Herald KK, Singh Z, Sridhar M, Srikanth I. Diet and exercise in obesity: A case report from India. Int J Nutr Pharmacol Neurol Dis 2015;5:166-71
|How to cite this URL:|
Samuel A, Bazroy J, Purty A, Herald KK, Singh Z, Sridhar M, Srikanth I. Diet and exercise in obesity: A case report from India. Int J Nutr Pharmacol Neurol Dis [serial online] 2015 [cited 2020 Jun 5];5:166-71. Available from: http://www.ijnpnd.com/text.asp?2015/5/4/166/167497
| Introduction|| |
Obesity is an excess of body fat, resulting in adverse health effects. Obesity has emerged as a major public health problem. The prevalence of obesity is increasing in almost all parts of the world. The prevalence of overweight and obesity among population aged 30 years and above was 42% and 12% globally, respectively. In a multicentric study done in India, the prevalence of obesity was 72.5% among women and 1.1% among men. Obesity is much more than a cosmetic problem, as its associated health problems are increasing. According to some estimates, it is responsible for greater health-care costs than is either smoking or problem drinking. The development of overweight and obesity is extremely complex and multifactorial. Ultimately, however, it is the imbalance of energy intake being greater than the energy expenditure that contributes to weight gain. This report presents the gradual onset of obesity in a rural Adult female and explores the various risk factors as well as strategies for obesity management at the lifestyle clinic under the Department of Community Medicine, P.I.M.S.
| Case Report|| |
The benefits of autobiographical narration are well described in the literature. A rural mother aged 58 years, who had been a widow for the past 29 years at the time of appointment, presented to the chest clinic with complaints of breathlessness while doing normal day-to-day activities. Excessive sleepiness was observed during the day hours as she dosed off performing normal daily chores. Her sleeping behavior included loud snoring, as observed by her family. The breathlessness was not associated with postural variation, nor did it disturb her sleep.
She was a mother of five children: Three sons and two daughters. Following the birth of her youngest daughter, her husband had committed suicide due to financial stress and other reasons unknown to her. This had occurred 28 years earlier. This tragic incident along with raising her children alone was a source of emotional stress and challenge for her. After this incident, she began to gradually gain weight. The knee joint pain that accompanied further lowered her interest in any physical activity. As all her children were now well settled, the economy of the household improved, and this led to the family adopting junk food into their diet. This correlation was elicited from the history given by the patient. The fast foods are available in this part of rural India and she began to use it often as the economy of the household improved.
Excerpts from the original history given by the patient: As all her children are now well settled, the economy of the household improved and this has led to the family adopting junk food into their diet. In the recent past (2-4 years) oil fried snacks, cakes, biscuits, fried non vegetarian food, and carbonated drinks became their Tiffin and parcel.
Even though she was known for chewing tobacco from the age of 16 and stopped the same 2 years earlier, following the marriage of her youngest daughter, decreased physical activity, increased energy intake, junk diet, multiple pregnancy, emotional stress (widow/raising five children), tobacco cessation, and physical limitations such as knee joint pain and breathlessness that limited her activity were identified as the known risk factors for her obesity.
She was morbidly obese as she weighed around 150.6 kg against a height of 157 cm [body mass index (BMI) 61.09]. She was diagnosed with morbid obesity (based on BMI), chronic type II respiratory failure, and obstructive sleep apnea. Her clinical history and examination along with lab investigations ruled out the possibility of hypothyroidism and Cushing's syndrome. She was not on any steroids nor was she on any antidepressants. She was a nonalcoholic and a nonsmoker. She was brought to our lifestyle clinic to motivate herself into healthy lifestyle practices.
The lack of complete understanding regarding the etiology of obesity makes the management of it more difficult. Predisposing factors must ultimately operate on an individual level, and individuals should adopt behaviors conducive to a healthy body weight. However, the environment will also need to be changed, in part through public health efforts, to have a major impact in decreasing body weight on a population-wide basis. Community development should include ample opportunities for physical activity, such as walking and biking paths, neighborhoods that encourage local travel, buildings with stairs more conveniently located than elevators, physical activity in schools, and other initiatives. The patient was under our care for 4 weeks.
Initial evaluation included measuring height using a stadiometer and weight using a digital bathroom scale. BMI was calculated with the above data and it was found to be 61.09. The blood investigations to rule out diabetes, hypothyroidism, and Cushing's syndrome were done, and all were found to be negative.
- Current and past exercise habits
- Exercise was not done. She was a homemaker and preferred to stay indoors. Her home had a courtyard that was too small for carrying out walking exercises. Nor was she involved in any other exercise. Moreover, her work did not involve any strenous physical activity. For the past 2 years after the marriage of her youngest son, she was not involved in any work, including household work. Following this, she had an abnormal increase in weight gradually, which further worsened her knee joint pain and her breathlessness. Her breathlessness worsened from occurring on doing strenous work to even while doing normal activities.
- Current and past dietary habits
- She consumed a rural South Indian diet, which was mainly rice-based. The rice-based diet was compounded by sugary tea and coffee along with snacks in the morning and evenings. The snacks included cakes, biscuits, chips, and cutlets. She had a nonvegetarian diet once in 3 days. She consumed fruits occasionally. Legumes, pulses, and nuts were a rarity in her diet. She consumed a minimal amount of vegetables, along with rice-based foods.
- No family history of obesity
- The patient expected to lose excess weight, as she found that it disrupted her normal day-to-day activities. She understood that the reason for her breathlessness as well as her knee joint pain was obesity.
We assessed the patient's readiness to change using the transtheoretical model of change. The five stages include five stages of changes: Of precontemplation, contemplation, preparation, action, and maintenance. The patient was found in the precontemplation phase, where she had some limited motivation to change. With the advice on how she could lead a normal life, she gradually moved into the contemplation phase, where she began making small changes, and subsequently into the action phase.
The goal setting was planned on a weekly basis. The first week was planned for behavioral modification, followed by minor changes in diet and mild physical activity. As the weeks progressed, we gradually changed her diet to a low carbohydrate, low fat and low protein diet. Similarly, we increased the physical activity from indoor activity to outdoor physical activity. The goals were specific, measurable, and achievable.
Self-monitoring techniques included diet records and an activity log. This helped to improve the patient's activity and set new goals as the days progressed. Studies have demonstrated that people who keep diet and activity records are more successful in weight management.
Increased energy expenditure is the other half of the energy balance equation that affects body weight, the other being food intake. Total physical activity consists of both exercise and activities performed throughout the day. Daily activities were planned and modified, taking into consideration of her physical limitations [breathlessness and knee joint pain], readiness to change, and resources. Motivational counseling on following a healthy lifestyle was given at least twice on a daily basis.
The goal from the point of view of physical activity was to achieve a minimum 3 h of moderately vigorous physical activity on most days of the week, either through exercise or activities throughout the day. Initially, we started with hand cycling for 10 min at four occasions on a single day. Along with this, she was asked to walk 150 steps indoors. She was able to do only 75 steps on the first day, but gradually she improved and by the end of the 1st week was able to complete 450 steps intermittently in a day. She was able to complete 100 steps in a single episode. The frequency as well as duration of hand cycling was also increased to 3-4 times/day, and the duration from 15 min to 20 min. Breathing exercises were also started from the third day. The patient did it regularly at an interval of 2 h during the day hours. The duration of breathing exercises varied from 5 min to 15 min.
By the middle of second week, she was able to walk outdoors. Initially, she was able to cover 500 m in 90 min. But by the end of her hospital stay (20th day), she was able to cover 1.5 km in 60 min on two occasions (morning and evening). This activity was undertaken along with hand cycling and breathing exercises.
The solution to weight loss is a whole-food, plant-based diet. It is a long-term lifestyle change, rather than a quick-fix fad. Dietary modification includes decreasing calorie intake and promoting low-calorie diet. Limiting the consumption of high-calorie foods by limiting the portion size and the number of servings was the principle followed in all her meals. We included more of fruits, vegetables, legumes, and whole grain cereals in her diet. Between the servings, there would be a minimum of 4 h, which was the time given for the food to be digested. In between, no supplementary meals were given. Only fruit or vegetable juices and drinking water were provided between meals. Lemon juice with honey was the first drink that she had soon after waking up. Breakfast would be sumptuous, followed by a lighter lunch, then an even lighter dinner. Milk was replaced with curd, which was gradually reduced and stopped during the subsequent weeks. Sugar and all nonvegetarian foods were restricted. We tried to replace milk with soy milk, but she was not able to cope with the taste.
From rice-based meals, we trained her to savor wheat-based meals with more of fresh vegetable salads, fresh fruits, legumes, peas, nuts, and fruit and vegetable juices. Her morning breakfast included oats/porridge, two slices of wheat bread with fruit jam spread, fresh vegetable salad, legumes, and a small cup of nuts (25 gm). Her lunch included 2 chappathis, 100 gm of rice, boiled vegetables, thick dhal, buttermilk, and fruits. Her dinner included 2 chappathis or wheat dosa along with coconut chutney, fresh vegetable salad, and vegetable juices. Fruit juices and vegetable juices were provided at an interval of 2 h. Gradually, we reduced the amount of rice served and our goal was to make her diet free of rice. We were able to gradually change her diet within a period of 7 days to a plant-based, whole-food diet.
Apart from the above mentioned diet, in the third week, she was subjected to fruit/vegetable juice fast for three days. The patient tolerated this diet on an alternate day basis. This had drastic weight loss effect on the patient.
| Discussion|| |
Obesity is a public health problem with multiple risk factors and so is its management complex. Multiple pregnancies, stress, smoking cessation, problematic alcohol use, physical limitations, medical conditions like hypothyroidism, Cushing's syndrome, mental illness, and medications/drugs like steroids and antidepressants are some of the predisposing factors to obesity., Large-scale genome-wide association studies have also established a genetic basis for obesity in the general population.
Though she claims to consume only a few mouthfuls that would suffice to keep her back upright, her children say that it is, in fact, quite the contrary. Several studies have proved that people always underestimate energy intake as seen in this patient also. Nutritional factors related to obesity are relative to total energy expenditure. Due to being overweight, she rarely moved outside of her house. The knee joint pain that was incident further worsened her ability for any physical activity. The breathlessness has worsened over the years proportional to the weight gain which further made her immobile. Several studies have shown that the predominant factor related to obesity is a decline of overall physical activity.,,,
Sedentary lifestyle is a type of lifestyle with no or irregular physical activity. A person who lives a sedentary lifestyle may colloquially be known as a couch potato. This patient was indeed a couch potato. A study done in rural Taiwan found that women, those with lower education, those with lower income, smokers, and chewers of betel nut exercised significantly less than their counterparts. A study done among women in USA has shown that the age-adjusted prevalence of women's obesity was as high as 41.4% for those with no leisure-time physical activity in the past month. A similar study done in rural South India showed that leisure-time physical activity had a significant negative relation to waist circumference (beta = -0.002) and BMI (beta = -0.008).
Because of the impact on energy balance, physical activity contributes to the prevention and control of weight gain. In our interventional approach, we were able to attain a reduction of 7.17% using lifestyle modification, as described above. Hagan et al. reported reductions in weight losses of 7.5%, 5.5%, and 0.6% in women participating in 12 weeks of diet plus exercise, diet alone, or exercise alone, respectively. In our case, we observed that the weight loss progressed as we increased the duration of the exercise. Jakicic et al. reported that weight loss was improved in overweight and obese women with the addition of 200-300 min/week of physical activity. These findings are similar to the results reported by several studies,,, who demonstrated that weight-loss maintenance was improved when individuals engaged in the equivalent of ≈65 min/day of moderate-intensity physical activity. We designed the physical activity intervention at intermittent intervals as the patient did not get tired off and this also facilitated easy adoption of physical activity in her routine life. i.e., brisk walking two times, hand cycling every 3 h during day hours, and breathing exercises. Jakicic et al. reported that the strategy to include intermittent periods of physical activity throughout the day was effective for improving physical activity participation in overweight women across a behavioral weight-loss program.
The solution to losing weight is a whole food, plant-based diet, coupled with a reasonable amount of exercise. Studies from across the world have shown that vegans are anywhere from 1.8 kg to 13.59 kg slimmer than their meat-eating counterparts.,,,, By feeding on a plant-based diet along with exercise, several intervention studies have shown to decrease the weight by 4-7% of their body weight over 3 weeks.,,, All of these results show that consuming a whole-food, plant-based diet will reduce weight quickly over a period of 3-4 weeks., Losing body weight while on a plant-based diet is much less likely to occur if the diet includes too many refined carbohydrates. Sweets, cakes, pastries, and pastas also do not help. As long as one eats the right type of food, one will be able to achieve the desired weight.
Our intervention included avoiding sugars and bakery products. A whole-food, plant-based diet coupled with physical activity and a strongly motivated subject were the factors behind the success of this intervention.
The patient used non smoking tobacco in the form of tobacco chewing. Even after stopping this habit, she will always feel like tasting something in her mouth due to satiety reflex. To tackle this effect, we provided her with fresh fruit/vegetable juices at 2-h intervals.
We were able to reduce her blood pressure from 150/100 to 130/90 over a period of 20 days. This has been demonstrated in meta-analysis by Dickinson et al., that statistically significant effects were found for improved diet, aerobic exercise, alcohol and sodium restriction, and fish oil supplements: Mean reductions in systolic blood pressure of 5.0 mmHg [95% confidence interval (CI): 3.1-7.0], 4.6 mmHg (95% CI: 2.0-7.1), 3.8 mmHg (95% CI: 1.4-6.1), 3.6 mmHg (95% CI: 2.5-4.6), and 2.3 mmHg (95% CI: 0.2-4.3), respectively, with corresponding reductions in diastolic blood pressure. By small lifestyle modifications, normal BMI can be achieved.
We were able to achieve a weight reduction because of the high motivational level of the patient. Her family also played an important role encouraging her to lose weight. The rural women to accept a new diet which was quite alien to her was a challenge for us. She found it quite difficult to adjust with the new diet in the first few days but totally adjusted to it within a short period of 7 days. The hospital stay was another challenge. Being far away from her home and comfort zone, initially she was not willing for a longer stay in the hospital as required for the life style treatment. The success in reducing the weight over the subsequent weeks along with the constant counselling made her to stay and adhere to the lifestyle program.
We were able to achieve:
- Weight reduction: The patient presented with a weight of 150.9 kg on October 29, 2014. Over a period of 1 week, with gradual modification of diet and exercise, we achieved a weight of only 149.1 kg, a loss of only 1.8 kg. During the course of the intervention, after 9 days she weighed 146.2 kg while fully on diet modification but still picking up on physical activities. After 20 days, when she was adhering completely to our intervention program and a juice fast in the third week, we recorded a weight loss of 9.1 kg. After 4 days of the last record, we were able to record a weight of 139.8 kg
- Breathlessness: Her breathlessness gradually reduced from breathlessness even while doing normal activities to only during the performance of strenuous activities
- Snoring: By the end of the second week, the patient's relatives observed that her loud snoring behavior had reduced
- Blood pressure: She presented with a blood pressure of 150/100 mmHg. On discharge, her reading was 130/90 mmHg.
| Conclusion|| |
Obesity is the most ominous harbinger of poor health. With necessary lifestyle modifications, the trend can be reversed. There is no shortage of guidelines for shaping clinical practice. Clinical guidelines have proliferated in recent years, to the point where it is increasingly difficult even to be aware of all the guidelines and use them appropriately. Weight control has been the subject of extensive study and writing. The simple conclusion of weight control research is the need for dietary modification and increased physical activity. Treating professionals should devote time to counsel the patient and bring him/her back to a diet-and-physical activity regime that will solve this issue. Obesity is a serious illness that can be insidious in its development but literally fatal in its consequences. It is reversible, and obese individuals can normalize their BMI, as was tried with this patient.
The authors would like to thank the participant of this study and her family members. The author would also like to thank Mr. I. Srikanth and his team from the Physiotherapy Department for their efforts, and Mrs Maghida, Mrs. Mercy, and their team from the Dept. of Dietetics for their efforts in encouraging and advising the patient in reducing obesity.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Global health risks: Mortality and burden of disease attributable to selected major risks. Geneva: World Health organization; 2009. p. 1-69.
Report of ICMR-WHO study. Assessment of Burden of Non Communicable Diseases. New Delhi: Indian Council of Medical Research; 2006. p. 68-73.
Sturm R. The effects of obesity, smoking, and drinking on medical problems and costs. Health Aff (Millwood) 2002;212:45-53.
World Health Organization. Obesity: Preventing and Managaing the Global Epidemic. Geneva, Switzerland: WHO; 2000.p. 104-7.
Hankir A, Agius M. Review and overview: Autobiographical narrative and psychopathology. CEPiP 2013;1:254-60.
Astrup A, Rössner S, Van Gaal L, Rissanen A, Niskanen L, Al Hakim M, et al
.; NN8022-1807 Study Group. Effects of liraglutide in the treatment of obesity: A randomised, double-blind, placebo-controlled study. Lancet 2009;374:1606-16.
Hensrud DD. Obesity. In: Rakel RE, Bope ET, editors. Conn's Current Therapy 2002. Philadelphia, Pennsylvania: WB Saunders Co; 2002. p. 577-85.
Speliotes EK, Willer CJ, Berndt SI, Monda KL, Thorleifsson G, Jackson AU, et al
. Association analyses of 249,796 individuals reveal 18 new loci associated with body mass index. Nat Genet 2010;42:937-48.
Lichtman SW, Pisarska K, Berman ER, Pestone M, Dowling H, Offenbacher E, et al
. Discrepancy between self-reported and actual calorie intake and excercise in obese patients. N Engl J Med 1992;327:1893-8.
Tiwari R, Srivastava D, Gour N. A cross-sectional study to determine prevalence of obesity in high income group colonies of Gwalior city. Indian J Community Med 2009;34:218-22.
Thankappan KR, Shah B, Mathur P, Sarma PS, Srinivas G, Mini GK, et al
. Risk factor profile for non-communicable diseases: Results of a community based study in Kerala, India. Indian J Med Res 2010;131:53-63.
Gopinath N, Chadha SL, Jain P, Shekhawat S, Tandon R. An epidemiological study of obesity in adults in the urban population of Delhi. J Assoc Physcians India 1994;42:212-5.
Hill JO. Understanding and addressing the epidemic of obesity: An energy balance perspective. Endocr Rev 2006;27:750-61.
Wai JP, Wen CP, Chan HT, Chiang PH, Tsai MK, Tsai SP, et al
. Assessing physical activity in an Asian country: Low energy expenditure and exercise frequency among adults in Taiwan. Asia Pac J Clin Nutr 2008;17:297-308.
Seo DC, Li K. Leisure-time physical activity dose-response effects on obesity among US adults: Results from the 1999-2006 National Health and Nutrition Examination Survey. J Epidemiol Community Health 2010;64:426-31.
Komal W, Jaipanesh K, Seemal M. Association of leisure time physical activity, watching television, obesity and lipid profile among sedentary low-income south Indian population. East Afr J Public Health 2010;7:225-8.
Hagan RD, Upton SJ, Wong L, Whittam J. The effects of aerobic conditioning and/or calorie restriction in overweight men and women. Med Sci Sports Exerc 1986;18:87-9.
Jakicic JM, Marcus BH, Gallagher KI, Napolitano M, Lang W. Effect of exercise duration and intensity on weight loss in overweight, sedentary women: A randomized trial. JAMA 2003;290:1323-30.
Schoeller DA, Shay K, Kushner RF. How much physical activity is needed to minimize weight gain in previously obese women? Am J Clin Nutr 1997;66:551-6.
Klem ML, Wing RR, McGuire MT, Seagle HM, Hill JO. A descriptive study of individuals successful at long-term maintenance of substantial weight loss. Am J Clin Nutr 1997;66:239-46.
Jeffery RW, Wing RR, Sherwood NE, Tate DF. Physical activity and weight loss: Does prescribing higher physical activity goals improve outcome? Am J Clin Nutr 2003;78:684-9.
Ellis FR, Montegriffo VM. Veganism, clinical findings and investigations. Am J Clin Nutr 1970;23:249-55.
Key TJ, Fraser GE, Thorogood M, Appleby PN, Beral V, Reeves G, et al
. Mortality in vegetarians and non vegetarians: Detailed findings from a collaborative analysis of 5 prospective studies. Am J Clin Nutr 1999;70(Suppl):516S-24.
Bergan JG, Brown PT. Nutritional status of "new" vegetarians. J Am Diet Assoc 1980;76:151-5.
Appleby PN, Thorogood M, Mann JI, Key TJ. Low body mass index in non-meat eaters: The possible roles of animal fat, dietary fibre and alcohol. Int J Obes Relat Metab Disord 1998;22:454-60.
Dwyer JT. Health aspects of vegetarian diets. Am J Clin Nutr 1988;48(Suppl):712-38.
Shintani TT, Hughes CK, Beckham S, O'Connor HK. Obesity and cardiovascular risk intervention through ad libitium feeding of traditional Hawaain diet. Am J Clin Nutr 1991;53(Suppl):1647-51S.
Bernard RJ. Effects of lifestyle modification on serum lipids. Arch Intern Med 1991;15:1389-94.
Nicholson AS, Sklar M, Barnard ND, Gore S, Sullivan R, Browning S. Toward improved management of NIDDM: A randomized, controlled, pilot intervention using a lowfat, vegetarian diet. Prev Med 1999;29:87-91.
Dickinson HO, Mason JM, Nicolson DJ, Campbell F, Beyer FR, Cook JV, et al
. Lifestyle interventions to reduce raised blood pressure: A systematic review of randomized controlled trials. J Hypertens 2006;24:215-33.
Gupta AT, Siddhu A. Desirable factors for maintaining normal BMI of urban affluent women of Delhi. Indian J Public Health 2015;59:49-53.