Obesity, Associated Diseases and Potential Complications: Prevention and Treatment Strategy through Nutritional Intervention Combined with Physical Activity

Souza LP; Alves HHO; Santos LC; Fernandes L; Manoel R; Souza RP; Levada-Pires AC; Martins POF; Gorjao R; Cury-Boaventura MF

Research Article

Austin J Nutri Food Sci. 2021; 9(3): 1159.

Obesity, Associated Diseases and Potential Complications: Prevention and Treatment Strategy through Nutritional Intervention Combined with Physical Activity

Souza LP¹*, Alves HHO¹, Santos LC¹, Fernandes L¹, Manoel R¹, Souza RP², Levada-Pires AC¹, Martins POF¹, Gorjao R¹ and Cury-Boaventura MF¹

¹Institute of Physical Activity and Sport Sciences, Cruzeiro do Sul University, Brazil

²Incor-HCFMUSP, Brazil

*Corresponding author: Souza LP, Institute of Physical Activity and Sport Sciences, Cruzeiro do Sul University, Brazil

Received: September 21, 2021; Accepted: October 20, 2021; Published: October 27, 2021

Abstract

Obesity modulate the production of hormones and adipokines such as leptin, adiponectin, and resistin, thereby favoring the development of chronic Noncommunicable Diseases (NCDs). Nutritional intervention is a strategy used for its prevention and/or treatment. We analyzed the benefits of a nutritional intervention program combined with the practice of physical activity on body composition and NCD markers. Eighteen people with a mean age of 58 ± 8 years, weight of 73.68 ± 16.57 kg, Body Mass Index (BMI) of 28.30 ± 4.88 kg/m2, Waist Circumference (WC) of 95.72 ± 13.57 cm, waist/hip ratio of 0.80 ± 0.07, and body fat percentage of 35.22% ± 4.84% who practiced aquatic aerobics and/or swimming participated in a six-month nutritional intervention program with weekly meetings. Data collection was performed before and after the intervention. We evaluated BMI, body fat percentage, WC, and hip circumference as well as the levels of leptin, resistin, adiponectin, and insulin. Nutritional intervention combined with physical activity contributed to a reduction in weight by 1.47% (p < 0.05), BMI by 1.32% (p < 0.05), and the plasma concentration of leptin by 18.04% (p < 0.05) and resistin by 8.70% (p < 0.05). There was no significant change in the hormones adiponectin and insulin. Total cholesterol decreased by 22% (p < 0.01) and low-density lipoprotein cholesterol (LDL-c) by 51.80% (p < 0.0001). During the follow-up period we observed a reduction in weight, BMI, leptin, resistin, total cholesterol, and LDL-c. Therefore, we conclude that changes in eating habits along with the performance of physical activity assist in the treatment of overweightness and obesity and, thus, prevent associated diseases.

Keywords: Obesity; Adipokines; Nutritional intervention; Physical activity; Inflammation; Covid-19

Introduction

Each year, 2.8 million people die from obesity-related diseases such as hypertension, dyslipidemia, and metabolic syndrome. Economic burden is one of the various negative aspects of obesity because the expenditure on healthcare to meet the needs of individuals with chronic Noncommunicable Diseases (NCDs) is high both in developed countries, including the United States of America, and developing countries such as Brazil [1]. Studies show that in 2018, Brazil spent 3.45 billion reais in the Unified Health System for the treatment and follow-up of patients with obesity, hypertension, and diabetes [2].

Obesity is characterized by the accumulation of triacylglycerol inside adipocytes caused by an imbalance between food intake and total energy expenditure [3,4]. The accumulation of visceral fat leads to increased metabolic risk, causing problems such as diabetes and liver steatosis, in addition to the risk of developing triglyceride storage dysfunction, which contributes to the development of dyslipidemia [5]. Because white adipose tissue is the largest endocrine organ, obesity leads to an imbalance in the production of some adipokines such as IL-6, adiponectin, leptin, resistin, apelin, and visfatin [6].

Hypertrophy and hyperplasia of adipocytes result in local hypoxia leading to cell death and increased flow of fatty acids. These metabolic processes combined with the imbalance of adipokines, including IL-6, leptin, and resistin, which have proinflammatory properties, contribute to the development of subclinical inflammation in people with obesity and favor the development of comorbidities [7,8].

Leptin is one of the hormones responsible for the increased activity of the sympathetic nervous system, which in turn controls renal and vascular blood pressure. As a result, the increase in plasma leptin levels is associated with the occurrence of hypertension in people with obesity [9,10].

Resistin plays a role in the storage and use of energy in the form of triacylglycerol and has been associated with the development of chronic diseases linked to obesity, such as type 2 diabetes and cardiovascular diseases [11].

On the other hand, in addition to influencing insulin sensitivity, adiponectin has anti-inflammatory and antiatherogenic properties and is therefore considered as an antidiabetic hormone. Obesity, insulin resistance, diabetes, hypertension, coronary artery disease, and high risk for myocardial infarction are associated with low serum levels of adiponectin [12].

Since the beginning of 2020, obesity, along with NCDs, is a matter of increasing concern due to the COVID-19 pandemic, and several studies show that obese patients tend to have worse disease progression, a long period of hospitalization, and high morbidity and mortality [13]. Compared to eutrophic individuals and patients without comorbidities, obese individuals are in a subclinical inflammatory state, and the presence of another inflammatory stimulus, such as COVID-19 infection, facilitates an inflammatory burst that promotes complications [14]. In addition, individuals with obesity elicit a delayed and ineffective immune response [15].

Furthermore, the SARS-CoV-2 virus binds to target cells through the spike protein, which in turn comes into contact with the Angiotensin-Converting Enzyme 2 (ACE2). Both lung and adipose tissues have high expression of ACE2, which makes obese individuals highly vulnerable to infection [16].

Inadequate dietary choices, such as having a high intake of foods with high calorie, high sucrose, and low fiber levels, are closely related to obesity. Strategies that alter these behaviors can positively influence the nutritional status of the population and reduce the incidence of obesity and NCDs [17]. However, nutrition education has been shown to be more effective when it focuses on behavior/action and not just on knowledge acquisition by the individuals; therefore, any strategy needs to be based on three pillars-theory, research, and practice [18].

In addition to changes in food consumption and physical activity, aerobic exercises are strategies that especially contribute both to weight loss and the maintenance of this loss [19]. Aquatic exercise activities are shown to be effective for weight loss and anthropometric changes in previously sedentary adults, even in a short period of intervention [20]. However, a previous study by our group showed that aquatic exercises performed for a long period did not promote changes in body composition, despite improving the inflammatory subclinical state and NCD markers [21].

In this study, we evaluated the benefits of a nutritional intervention program on body composition and NCD markers in individuals who practice aquatic exercise.

Methods

Sample

The participants were screened and recruited in a structured aquatic physical activity program at a community-based health and fitness center at the Institute of Physical Activity and Sport Sciences of the Cruzeiro do Sul University. The study included 18 participants (16 women and 2 men) with a mean age of 58 ± 8 years, weight of 73.68 ± 16.57 kg, Body Mass Index (BMI) of 28.30 ± 4.88 kg/m2, Waist Circumference (WC) of 95.72 ± 13.57 cm, Waist/Hip Ratio (WHR) of 0.80 ± 0.07, and body fat percentage of 35.22 ± 4.84%.

The participants underwent a supervised 12-month nutritional intervention program which involved performing 60 min of exercise twice a week. The training sessions were supervised by trainers qualified in the modalities of swimming (x participants) and/or water aerobics (y participants), and the sessions were conducted in the Sports Center of the Institute of Physical Activity and Sports Sciences as described by Gondim [21].

With regard to the nutritional status, before the start of the nutritional intervention program, most participants (76%) were overweight (according to BMI) and 62% were classified as obese (according to body fat percentage). In addition, 19% of the participants were at a high risk and 76% were at a very high risk for developing Cardiovascular Diseases (CVDs) according to their WCs, and 43% participants were at a high risk for developing CVD according to their WHRs.

The participants were excluded from the study if they did not obtain at least 80% attendance in the training sessions and nutrition workshops, did not participate in the three steps proposed by our study (at baseline and after 6 and 12 months of regular exercise), and had not fasted for 8 h prior to blood collection.

With respect to medication, 11% of them had previously received a prescription for dyslipidemia, 38% for hypertension, 11% for diabetes mellitus, 22% for hypothyroidism, and 16% for anxiety and depression.

The nutrition workshops and data collection were conducted in the Sports Center of the Institute of Physical Activity and Sports Sciences. An informed consent form was obtained from all the participants before enrolling them in the study. Additionally, the study was approved by the Human Ethics Committee of the Cruzeiro do Sul University (approval number: 1179/CEPSH).

The study lasted for 10 months, and the nutritional intervention and data collection were performed in this period. Two data collections were performed in 2015, the first at the beginning of March before the nutritional intervention [pre-nutritional intervention (pre-NI)] and the last at the end of the nutritional intervention in early November (post-NI).

Anthropometric data (weight, height, hip circumference, WC, body composition, body fat percentage, and lean mass percentage) were recorded, and 10 mL blood samples were collected in sterile vacuum tubes by healthcare professionals. Nutritional anamnesis was performed using the Food Frequency and Habitual Diet Questionnaire.

Nutritional intervention

After the first data collection, the participants were recruited in a group nutritional intervention program that included nutrition workshops conducted for 50 min once a week before or after the practice of physical activity for a total duration of 6 months and a total of 16 nutrition workshops.

The nutritional intervention strategies included nutritional guidance (dietary choices, questions about specific food, adequate substitutes, etc.), assessment of food intake (by maintaining records in a food diary), and development of a dietary plan (on an individual basis).

The workshops addressed various topics and included a theoretical background and language appropriate to the public. The topics were addressed following a planned and consistent line of reasoning for the assimilation and understanding of the contents according to the Food Guide for the Brazilian Population and other recommendations [22- 24]. To facilitate engagement and understanding, practical activities such as tastings, competitions, and games were carried out.

In the first 3 months, the topics covered general concepts of nutrition such as the classification of foods according to the food pyramid and correct food portioning and labeling. In the next 3 months, the workshops addressed topics related to illnesses resulting from inadequate nutrition with a sequence of meetings on NCDs, as shown in Table 1.

Table 1: Topics addressed in the nutrition workshops included in the study.




  
    Workshop Topics
    Methodology
    Reference
  
  
    Nonregulatory Eating Behavior.

      Food vs. Feelings
    Oral explanation and group discussion
    Aquino and Philippi [25]
  
  
    Diet is More Than Nutrient Intake. Basic    Guidelines for a Balanced Meal
    Oral explanation and group discussion
    Brazil [22]
  
  
    Ideal Food Choice-Food Categories-Packaging
    Video:

      “The farce of packaged juices”
    Brazil [22]

      Brazil [26]
  
  
    Understanding Food Labels
    Oral explanation and label analysis through game
    Brazil [26]
  
  
    Knowing the Food Pyramid.

      Food Groups
    Dynamic activity: building the food pyramid with    real food
    Philippi [27]
  
  
    Knowing the Food Pyramid.

      Portions
    Dynamic activity: identification of portions    (daily quantity and caloric value of food)
    Philippi [27]
  
  
    Do you know what chronic noncommunicable diseases    are?
    Visual resource and oral explanation
    Cuppari [28]
  
  
    What is Diabetes?-Part 1
    Dynamic activity: the relationship of sugar    dosages with corresponding foods
    SBD [24]
  
  
    What is Diabetes?-Part 2

      Diagnosis/Treatment/Control
    Visual resource, oral explanation, and tasting    light passion fruit mousse
    SBD [24]
  
  
    What is Hypertension?-Part 1

      Causes/Treatment/Control
    Visual Resource and Oral Explanation
    SBC [23]
  
  
    Knowing More About Sodium.

      Uses/Legislation/Risks
    Visual resource and oral explanation

      Label analysis
    BRAZIL [29]

      SBC [23]
  
  
    Seasonings that Replace Salt
    Dynamic activity: preparation of herbal salt.

      Tasting: ricotta paté with herbs
    -----
  
  
    The Fat in our Body and its Relationship with    Atherosclerosis.

      Functions/Classifications/Risks
    Visual resource and oral explanation
    Cuppari [30]
  
  
    The Fat in our Diet: Classifications
    Dynamic activity: recognizing the types of fats
    -----
  
  
    What are Skimmed, Semi-Skimmed, Light, and    Zero-Fat Products
    Dynamic activity: recognizing low-fat products-tasting
    Brazil [31]



Table 1: Topics addressed in the nutrition workshops included in the study.

In addition to nutrition workshop participation, the participants received a food plan formulated based on each individual’s dietary habits and caloric needs according to the nutritional recommendations of the World Health Organization (WHO) and taking into account the deficiencies of each individual as well as micronutrient requirements according to the technical regulations on the recommended daily intake of vitamins and minerals [32].

Dietary plans were developed according to the diet guidelines for weight loss, which establish an energy deficit of 500 kcal to 1000 kcal [30] in relation to the total energy requirement and taking into account the calculation of the basal metabolism rate and physical activity factor. The caloric value corresponding to the energy requirement was obtained through the standard calculation proposed by [33], which depends on gender, age, and nutritional status.

The structure of the food plan given to the participants included foods selected by the nutritionist and a list of three options for the replacement of each food so that the diet could be varied. Both the dietary plan and habitual diet analyses were performed using the DietPro^® software.

The physical activity factor was evaluated according to the FAO [33] parameters, which stipulate the following levels for overweight men and women: sedentary (1.0/1.0), moderately active (1.12/1.16), active (1.29/1.27), very active (1.59/1.44). Because the activity modality was classified as moderate and had a short duration and a frequency of up to twice a week, the “moderately active” parameter was used.

Assessment of body composition

The anthropometric evaluations were conducted through the measurement of weight, height, and hip and WCs using an electronic scale, a stadiometer, and nonelastic tape measure, respectively [34,35]. The guidelines of the WHO [35] were followed to obtain these data.

The assessment of the nutritional status of each participant was performed by calculating their BMI and classifying them based on it. BMI was calculated using the following formula: weight divided by height squared. The participants were classified as adults (>20 to <60 years) and elderly (>60 years), this study included 10 elderly and 8 adult participants. For the risk factors of WC and WHR, the parameters established by WHO [36], were used.

The evaluation of body composition (fat mass in kg and percentage, muscle mass in kg) was performed using the bioimpedance test according to the manufacturer’s standard recommendations. The Bioimpedance Biodynamics 310e^® (Biodynamics Corporation USA and/or TBW Importadora Ltd.) was used for all participants. To perform the bioimpedance test, the participants had to refrain from consuming caffeinated foods for a period of 24 h and from performing physical exercise for 12 h.

Blood sampling

Blood samples were collected after 8 h of fasting and 24 h after the last training session for evaluating the biochemical markers of NCD. Blood samples (20 ml-10 ml in an EDTA-containing tube and 10 ml in a dry tube) were collected from the antecubital vein before the training session and 6 months and 12 months after the training began. The serum and plasma were separated by centrifugation for 10 min at 1000 ×g and were subsequently stored in aliquots at -80^oC until further analysis.

Analysis of Risk Markers for NCDs

Lipid profile: The plasma samples were used for lipid profile analysis using the enzymatic colorimetric test. Bioclin^® kits (Belo Horizonte, MG, Brazil) were used to determine total cholesterol, High-Density Lipoprotein Cholesterol (HDL-c), and Low-Density Lipoprotein Cholesterol (LDL-c) according to the manufacturer’s instructions. The analysis was performed using a spectrophotometer at a wavelength of 500 nm (SpectraMax, Molecular Devices, CA, USA).

Hormonal assessment: The serum samples were used for determining the levels of the hormones adiponectin, leptin, resistin, and insulin using the enzyme linked immunosorbent assay method (Quantikine^® Colorimetric Sandwich ELISAS or Duoset^®, R&D Systems, Minneapolis, USA) according to manufacturer’s instructions.

Statistical Analysis: All data were expressed as mean ± standard deviation. The statistical analysis was performed using the Prisma^® software version 6 and Student’s t-test. The significance level was set at p < 0.05 for all parameters. The Kolmogorov-Smirnov test was used for the analysis of normality between variables. The Holm-Sídák test was used for evaluating parametric data, and the Friedman test was used for evaluating nonparametric data.

Results

Assessment of food intake

We observed a 14% reduction in total energy intake post-NI (p<0.01), which promoted a negative energy balance when comparing the usual and proposed diets. There was no change regarding the distribution of macronutrients of the total caloric intake according to FAO [32].

Assessment of Body Composition

After the nutritional intervention, there was an increase of 9% (from 2 to 3 participants) in the percentage of eutrophic individuals (according to BMI) and a 19% reduction (from 9 to 5 participants) in obese individuals (according to body fat percentage). In addition, there was a 9% reduction in the percentage of participants at a very high risk for CVD according to WC and an increase of 14% in the percentage of participants without risk according to WHR.

The nutritional intervention program combined with the practice of physical activity contributed to a reduction in the weight of 1.47% participants (Figure 1A) and, consequently, to a reduction in the BMI of 1.32% participants (Figure 1B). However, there was no significant change in AC, body fat percentage, and WHR (Figure 1C, 1D and 1E).

Figure 1: Experimental design.

    
    
    Figure 1: Experimental design.

Lipid profile assessment

There was a reduction in the plasma concentration of total cholesterol (22%) and LDL-c (51.80%) after the nutritional intervention (Figures 2A and 2B). With regard to the HDL-c fraction and triglyceride concentrations, the participants showed no changes (Figures 2 C and 2D).

Figure 2: Evaluation of caloric intake before and after nutritional intervention.

    
    
    Figure 2: Evaluation of caloric intake before and after nutritional intervention.

Hormonal assessment

The nutritional intervention caused a significant decrease in the plasma concentrations of leptin (18.04%) and resistin (8.7%) (Figures 3A and 3B) in the participants who practiced aquatic exercise. There was no significant change in the participants in terms of the hormones adiponectin and insulin (Figures 3C and 3D).

Figure 3: Evaluation of anthropometric parameters before and after the nutritional intervention. We determined weight (A); body mass index, BMI (B); waist circumference, WC (C); body fat percentage (D); and hip circumference, HC (E). The values are presented as mean ± standard deviation for 18 participants. *p < 0.05 for comparison between values before and after the nutritional intervention.

    
    
    Figure 3: Evaluation of anthropometric parameters before and after the
nutritional intervention.
We determined weight (A); body mass index, BMI (B); waist circumference,
WC (C); body fat percentage (D); and hip circumference, HC (E). The values
are presented as mean ± standard deviation for 18 participants. *p < 0.05
for comparison between values before and after the nutritional intervention.

Figure 4: Evaluation of lipid profile before and after the nutritional intervention. We determined the total cholesterol (A); LDL-c: Low-Density Lipoprotein Cholesterol (B); triglycerides (C); and HDL-c: high-density lipoprotein cholesterol; (D) in plasma. The values are presented as mean ± standard deviation for 18 participants. **p < 0.01 and ****p < 0.001 for comparison between values before and after the nutritional intervention.

    
    
    Figure 4: Evaluation of lipid profile before and after the nutritional intervention.
We determined the total cholesterol (A); LDL-c: Low-Density Lipoprotein
Cholesterol (B); triglycerides (C); and HDL-c: high-density lipoprotein
cholesterol; (D) in plasma. The values are presented as mean ± standard
deviation for 18 participants. **p < 0.01 and ****p < 0.001 for comparison
between values before and after the nutritional intervention.

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Citation: Souza LP, Alves HHO, Santos LC, Fernandes L, Manoel R, Souza RP, et al. Obesity, Associated Diseases and Potential Complications: Prevention and Treatment Strategy through Nutritional Intervention Combined with Physical Activity. Austin J Nutri Food Sci. 2021; 9(3): 1159.

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