Chapter 2 Review of Related Literature

This chapter is composed to two parts. The first part, Obesity, is composed of four topics: the factors that cause obesity, including eating behaviors, and lifestyle factors; the pathophysiology of obesity; the effects of obesity and methods of measuring obesity. The second part is the summary of the entire chapter. Obesity Health professionals define obesity as an excess amount of body fat. Over the last decade, obesity has become one of the most evident yet most neglected public health problems. Obesity is a condition that can affect all age and socioeconomic groups, as well as both developed and developing countries. Coexisting with undernutrition, globesity is taking over many parts of the world; and if immediate action is not taken, many will suffer from an array of severe health disorders. (http://www.who.int/dietphysicalactivity/publications/facts/ obesity/en/2010) There are approximately 350 million obese people (BMI 30.0 kg/m 2) and over 1 billion overweight people (BMI 25 kg/m 2) in the world. Over all about 2.5 millions deaths are attributed to overweight/obesity worldwide. (WHO, 2008) A study by David Rose (2010) had also predicted that eight out of ten men and almost seven in ten women will be obese by 2020. While data suggests that

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childhood obesity may be leveling off, adult obesity is expected to rise. The report predicts a higher incidence of diabetes, strokes and heart disease in the future. General Factors Related to Obesity Eating Behaviors High- calorie food intake is said to be one of the major causes of obesity. Studies that have been conducted by Bobroff et.al, (1986); Ello-Martin et.al., (2005); & Rolls (1985) as cited by Wardle (2006) have shown that calorie consumption is higher when a certain meal consists of 1) a variety of foods as opposed to a single food type, 2) when the food is more palatable, and 3) when it is presented in more energy-dense formulations. Skipping meals is one of the main concerns that are usually overlooked upon under eating behaviors. According to a study conducted by Hilbrecht and Zuzanek (2005), teens who were obese were much more likely to skip breakfast (34.4%) than their classmates of normal weight (21.1%). Also, they were less inclined to supplement their diets with vitamins (22.9%) than those students of normal weight (35.3%). Another characteristic of eating behaviors that has attracted a good deal of interest is stress. Although stress can cause both hypophagia (under-eating) and hyperphagia (over-eating), most people show a tendency to increase in their intake of sweet and fatty foods more than protein under stress, which may be a part of a coping response. (Wardle & Gibson, 2002 as cited by Wardle, 2007).

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In lieu of the many developing societies, systems of food production, storage and distribution have eradicated food scarcities of the past and have created an increasingly attractive and diverse food supply. Social norms related to eating have now changed, as snacking, eating on the go or eating out of home are now common and have contributed to a substantial ingestion of a large portion of calories. According to a study conducted by Hilbrecht and Zuzanek (2005), almost twice as many obese teens (23.7%) had lunch at a fast food restaurant compared to normal weight students (12.4%). Fast foods, characterized to have big servings with an equally large number of calories, have become all the rage, and people are now given more control over food choices. Portions have increased for meals and snacks, with growing evidence that people eat more when presented with larger portions. (Ello-Martin et.al, 2005 as cited by Wardle, 2006)

Activity Level Physical activity has three main components: occupational work, household chores and leisure-time physical activity (World Health Organization, 2000). Cross-sectional data in studies often reveal an inverse relationship between BMI and physical activity. In a study conducted by Bassett, et.al (2008), increased energy expenditure required by activities such as brisk walking, cycling and public transit contributes to lower rates of obesity. Supporting evidence for this view comes from the developing nation of China, where the use of

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automobiles is rapidly increasing. In the 1980s, very few households in China owned motor vehicles, but 14% of Chinese households acquired a motor vehicle between 1989 and 1997. Bell et.al (2002), as cited by Bassett, et.al (2009), conducted a longitudinal study of 2485 adults (age 20 to 45 years) during this time period. They found that Chinese men who acquired a car experienced a 1.8kg greater weight gain and were twice as likely to become obese compared with men whose vehicle ownership remain unchanged. In a study conducted by the Hinchliffe (2004), the current advice of the Department of Health of the Philippines is for individuals to take at least 30 minutes of moderately intense activity (e.g. brisk walking) on at least 5 days a week. However, only around 37% of men and 25% of women currently achieve this target. The number of hours in watching television is also said to have a certain connection with the increase in the rate of obesity. In a study conducted by Tucker and Friedman (1989), people who viewed TV more than three hours a day were twice as likely to be obese as those who viewed less than one hour a day. A sedentary lifestyle begins to emerge with hours spent on watching TV rather than on playing physical activities. Obese persons, especially adolescents, consume large quantities of junk food while enjoying TV, and commercials tend to stimulate snacking. (Marmitt, 2009) In an Australian study, physical activity was not directly associated with being overweight. Instead, regardless of physical activity pattern, subjects who reported watching TV more than four hours daily were twice as likely to be

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overweight than subjects watching TV less than one hour per day (Salmon et al. 2000 as cited by Lahti-Koski, 2001). Hours of television viewing was also observed to be positively associated with BMI in Swedish men (Rosmond et al. 1996 as cited by Lahti-Koski, 2001) and US women but not men (Jeffery and French 1998 as cited by Lahti-Koski, 2001). Similarly, subjects spending more than 35 hours a week of their leisure time sitting down were 1.6 times more likely to be obese than subjects who spent less than 15 hours per week sitting down (Martnez-Gonzlez et al. 1999 as cited by Lahti-Koski, 2001).

Alcohol Consumption A number of studies about the relationship between alcohol consumption and obesity have been inconsistent. According to a study conducted by Yeomans (2010), alcohol is one of the factors that can possibly contribute to unnecessary weight gain; that when consumed before or after meals tends to increase food intake, probably through enhancing the short-term rewarding effects of food. And moderate consumption of alcohol increases slightly the BMI and risk for obesity in men and decreases the BMI and risk for obesity in women (Janssens et al., 2001). However, most of the studies have reported that the contribution of alcohol to the body mass index of the population is minor. Beer consumption in Belgium seems not to be related to higher BMI and increased risk to obesity. (Janssens, et.al., 2001). In most of the studies reporting a positive association, this finding was restricted to men, whereas in women, the association has usually been the

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inverse (Molarius and Seidell 1997, Westerterp et al. 1999, Brunner et al. 2001 as cited by Lahti-Koski, 2001).

Smoking Habits As with alcohol consumption, several studies have also pointed out that smoking habits actually have an inverse relationship with obesity. In a study conducted by Grabakauskas et.al. (2003), obesity was less prevalent among daily smokers than among non-smokers and occasional smokers in both genders. A study by Chiolero et al. (2008) made mention that weight gain may be limited by smoking because of increased energy expenditure and reduced food intake. This affirms the included study of Schutz et. al. (1986) stating that nicotine acutely increases energy expenditure and could reduce appetite which would explain why smokers tend to have lower body weight than do non-smoker and why smoking cessation is frequently followed by weight gain. Included in the study of Chiolero et.al. is the one by John et.al. (2005) stating that a single cigarette has been shown to induce a 3% rise in energy expenditure within 30 minutes. Results in a study by Rasky et.al. (2004) state that for women and men, in comparison to non- and ex-smokers, smoking is significantly correlated with lower body mass index (BMI). In contrast, heavy smoking and smoking cessation are significantly associated with higher relative weight. Similar results were presented by Barnia et.al. saying that In comparison to nonsmokers, smokers of the average number of cigarettes have lower body mass index. Among smokers,

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however, increased amount of smoking tends to be positively associated with body mass index, particularly among men. Waist-to-hip ratio is positively associated with amount of cigarettes smoked per day, among both men and women. Smoking that, when not adequately dealt with, would lead to a spurious positive relation between obesity and length of life (Calle et al. 1999, Manson et al. 1995) because they believe that smoking can make one thin. And according to Frijters and Baron (2009), obesity seems to protect one against the likelihood of taking up smoking to the tune of being 2.1 percent less likely to be a smoker this period if one was obese the last period. Hinchliffe et al. (2004) has mentioned that the government of London had a campaign that has relied heavily on shock tactics, employing unashamedly graphic depictions of arterial fat accumulation caused by smoking. However, the effect of smoking in energy expenditure was weaker among obese subjects and it was dependent in the degree of physical activity and fitness as the results of Audrain et.al. (1995). In a cross-sectional analysis by Healton et.al. (2006), smoking coupled with poor diet and low physical activity could counterbalance even overtake the slimming effect of smoking.

Pathophysiology of Obesity Obesity is a medical condition in which excess body fat has accumulated to the extent that it may have an adverse effect on health, leading to reduced life expectancy and/or increased health problems (http://en.wikipedia.org/wiki/Obesity, 2010). There are probably many factors that

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may influence or lead to obesity, but in this study, predisposing factors would include Age, Sex, Genetics, and Socioeconomic Status of the respondents. Moreover, factors that may precipitate the occurrence of obesity which are identified in this study are as follows: Eating Behaviors such as Skipping meals, Binge Eating, Emotional Eating, and eating heavy meals before bedtime. Also, Lifestyle Factors such as Activity Level, Alcohol Consumption and Smoking Habits may also precipitate this condition. Obesity results from skipping meals in such a way that when a person misses eating a meal for a specified period of time (breakfast, lunch, dinner), serum glucose levels tend to drop. This leads to food cravings, and eventually, an excess intake of calories and fat. Also, missing a meal would lead to risky metabolic changes (http://www.annecollins.com/dieting/skipping-meals.htm, 2009). Another factor is binge eating. This phenomenon, if not counteracted with purging, may lead to obesity in such a way that a person would tend to consume a larger amount of calories than needed by the body (http://www.casapalmera.com/articles/compulsive-overeating-and-eatingdisorder-treatment/, 2009). Next is emotional eating. This factor can precipitate the occurrence of obesity through the diversion of the persons attention away from stress and other dilemmas and towards food. Food becomes the outlet for comfort. And thus, too many problems, and too much thinking may result to eating, overeating, and ultimately, obesity.

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Eating before going to bed would also lead to obesity in such a way that there is low energy / metabolic requirements of the human body during night time due to decreased activity. At this end fat metabolism becomes slowed, and thus fat accumulation to the different body parts occur. A persons activity level may also be one factor that would lead to obesity. It can be thought of that the lesser physical activity a person is able to perform, he / she is at a greater risk to develop metabolic disorders, and ultimately, obesity (http://www.eurekalert.org/pub_releases/2002-04/ajoc-dpa041902.php, 2009). Furthermore, consumption of alcohol may also contribute to the occurrence of obesity. People who consume too much alcohol have good chance of making it to the Obesity chart. Pure alcohol contains 7 calories per gram. And if that is complimented with excessive drinking, it wont take much time before you find yourself in a severe life threatening problem of obesity (http://www.buzzle.com/editorials/8-26-2005-75508.asp, 2010). Also, Smoking has been correlated with obesity. This claim is due to the possibility that the influence of nicotine or other cigarette components may predispose a person to having a highly oxidative metabolism, leading to fal malabsorption, and ultimately, to obesity. Effects of Obesity The negative effects of obesity on health are beyond dispute. Excessive body fat represents a strong risk factor for several diseases; the most important of which ones are type 2 diabetes, hypertension, cardiovascular diseases and

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osteoarthritis. Most of these deleterious effects are more likely if the excess body fat is mainly stored in the upper body, with abdominal visceral fat being the most critical when evaluating the health risks of obesity. Moreover, obesity is associated with disability and poor perceived health (Wolk and Rssner 1996, Manderbacka et al. 1998, Doll et al. 2000, Ford et al., 2001 as cited by LahtiKoski, 2001). Diabetes Mellitus can also be a possible effect of obesity. According to Philippine Obesity Control Surgery Team (POCST), obese people are in a much higher risk to develop type 2 diabetes. This type of diabetes is a result of a high blood sugar level. POCST also highlights how obesity can lead to early heart attacks. Heart attacks become 5 to 7 times more probable and it knows no age. Other cardiovascular complications are also brought about by obesity, especially among older adults. The extra pounds or kilos is not only disfiguring but a most unhealthy baggage that takes its toll in terms of the development of otherwise preventable illnesses, like high blood pressure, heart disease, stroke, infertility, osteoarthritis, gall bladder disease, and many forms of cancer. Other illnesses are solely attributed to negative lifestyle habits like excessive alcohol intake, cigarette smoking and stress. This is because of the added stress on the liver as a result of insulin resistance and the excess fat. (Chua, 2008). Methods of Measuring Obesity In recent years, the body mass index (BMI) has become the medical standard used to measure overweight and obesity. Body Mass Index can be used to measure both overweight and obesity in adults. It is the measurement of

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choice for many obesity researchers and other health professionals. BMI is a direct calculation based on height and weight, and it is not gender-specific. BMI of 25 to 29.9 indicates a person is overweight. And a person with a BMI of 30 or higher is considered obese. Most health organizations and published information on overweight and its associated risk factors use BMI to measure and define overweight and obesity. BMI does not directly measure percent of body fat, but it provides a more accurate measure of overweight and obesity than relying on weight alone. (http://www.who.int/dietphysicalactivity/publications/facts/ obesity/en/, 2010) Another form of measurement is the waist-hip ratio. Waist-hip ratio or waist-to-hip ratio (WHR) is the ratio of the circumference of the waist to that of the hips. It is calculated by measuring the smaller circumference of the natural waist, usually just above the navel, and dividing by the hip circumference at its widest part of the hip. The ratio is applied both to women and men. (De Young, 2008) There are other methods of measuring fat that could pinpoint obesity. The most accurate measures are to weigh a person underwater or to use an X-ray test called Dual Energy X-ray Absorptiometry (DEXA). These methods are not practical for the average person, and are done only in research centers with special equipment. Skinfold thickness' are measures of the thickness of skin and subcutaneous (lying under the skin) fat at targeted sites of a person's body such as the triceps (the back of the upper arm). Measurements of skinfold thickness

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depend on the skill of the examiner, and may vary widely when measured by different examiners. Bioelectrical impedance analysis (BIA) involves sending a harmless amount of electricity through a person's body which estimates total body water. Generally, higher percent body water indicates a larger amount of muscle and lean tissue. BIA may not be accurate in severely obese individuals, and is not useful for tracking short-term changes in body fat brought about by diet or exercise. Weight-for-height tables, usually have a range of acceptable weights for a person of a given height. These tables are characterized to have several drawbacks; one is that there are many versions, all with different weight ranges. Another is that they do not distinguish between excess fat and muscle. A very muscular person may appear obese, according to the tables, when he or she is actually not. (http://showbizandstyle.inquirer.net/lifestyle/lifestyle/view/20080614142573/Beating-obesity, 2008) Summary Obesity characterized by an excess accumulation of fat and reflects on the most basic level, an overall positive balance between energy intake and expenditure. There are 3 classes of obesity as mentioned in the World Health Organization Portal (2010) as follows: Class I obesity, having a BMI of 30-34.9; Class II obesity, with a BMI of 35-39.9; and Class III obesity, with a BMI of 40 and above. One of the factors that can affect obesity is eating habits. Skipping meals, eating a heavy meal at night before bed, and stress eating are some of the practices that may lead a person to develop this type of malnutrition. Living a

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sedentary lifestyle is also a major factor. Being physically inactive for most of the time, or spending more time in watching television than in exercising may predispose a person to become more overweight than he or she is supposed to be. If not intervened, obesity can lead to several complications such as cardiovascular diseases, hypertension, osteparthritis and type 2 diabetes. Overall, the before mentioned facts from the various articles and studies helped in the conceptualization of this study since they point out sensible information about eating habits and lifestyle factors, and its implication to health and wellness. Furthermore, they help to heighten the awareness of people regarding this occurrence.