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CHAPTER1

INTRODUCTION
Obesity is defined as a condition of abnormal or excessive fat accumulation in
adipose tissue to the extent that health may be impaired (Garrow 1988). It is now considered
as a new world syndrome.

Generally, weight gain and fat storage in human body have been considered as signs
of health and prosperity. However with the increase in awareness regarding unhealthy weight
gain in the people, obesity is now regarded as a threat to the human health. Globesity, an
escalating global epidemic of overweight and obesity, is now so common that it is considered
as one of the most significant contributors to ill health replacing the more traditional public
health concerns like under nutrition and infectious diseases.

At the other end of the malnutrition scale, obesity is today’s one of the most blatantly
visible but neglected public health problem. Ironically, co-existing with under nutrition,
globesity is spreading in many parts of the world. In recent times obesity is perceived as a
first wave of a defined cluster of several Non-Communicable Diseases (NCD) both in
developed and developing countries. Obesity is a complex condition with serious social and
psychological dimensions affecting virtually all age and socio-economic groups and threatens
to affect both developed and developing countries.

In 1995, there were an estimated 200 million obese adults worldwide and 18 million
under five children classified as overweight. As of now, the number of obese adults has
increased to over 300 million. Contrary to conventional knowledge the obesity epidemic is
not restricted to only developed countries but has also spread in developing countries.
According to World Health Organization (WHO 2000) estimate, over 115 million people
suffer from obesity (Figure 1.1).

Globesity, a swelling global tidal wave of obesity and Diet Related Non-
Communicable Diseases (DNCDs), threatens to envelop us as globalization changes the
nature of the world’s nutrition. Yet another form of malnutrition - development driven obesity
is emerging among all age and socio-economic groups especially in countries caught up in the
swiftest societal transition. As a result DNCDs such as diabetes, cardiovascular disease,
hypertension, stroke and cancer which were previously regarded as ‘rich men’s diseases’, are
now escalating in developing countries also, super imposed on precarious health systems
already buckling under the double weight of communicable and other non-communicable
diseases.

The trends in obesity are not restricted to any one region, country or ethnic group. The
highest levels of obesity in middle and lower income countries occur in the Middle East,
Western Pacific and Latin America. Though less common in Asia, there is evidence that its
prevalence is increasing at an alarming rate throughout the life cycle. The problem appears to
be increasing rapidly in children as obesity in school children is already approaching 10%
not only in industrialized nations but also in industrializing nations including India (Yadav
2002). The increasing prevalence of obesity in population and particularly among children is
an early indicator of the global epidemic of health burden due to NCDs in developing
societies.

OBESITY - ETIOLOGY AND RISK FACTORS

The specific cause of obesity is still not known today. The two potentially premorbid
effects that begin to operate during adolescence are changes in the quantity and location of fat
(Mueller 1982). In girls, body fat changes from 17% of body mass to 24% over the period of
adolescence (Cheek 1968). In contrast to girls, boys lose body fat but the central deposition of
body fat increases almost five fold whereas this increase in females is only approximately
three fold (Goran ef al 1995). Maternal obesity increases transfer of nutrients across placenta
inducing permanent changes in appetite, Neuro-endocrine functioning and energy metabolism
(Whitaker and Dietz 1998). Rolls et al (2000) introduced the concept that as children grow
older they become less responsive to internal hunger and satiety and are more reactive to
environmental stimuli. According to Catherine et al (2001), children who inherit a paternal
polymorphism associated with altered expression of the insulin genes have increased risk of
developing early onset obesity. Lawrence (2002) reported that researchers have discovered a
hormone (Gastric inhibitory Polypeptide) secreted in small intestine playing an important role
in determining whether dietary fat is stored in adipose tissue or consumed as fuel. A variety
of factors affect the deposition of body fat. As with adult onset obesity, childhood obesity has
multiple causes centering on an imbalance between energy input of calories from food and
energy output (calories expanded in the basal metabolic and physical activity). Many
complex and diverse factors give rise to a positive energy balance. The current relative
adiposity is a product of the interaction between genetic predisposition-'with regard to the
storage of body fat and environment (low physical activity, high availability of calorie-dense
foods) that is increasingly permissive to the expression of that genetic tendency. The recent
epidemiological trends in obesity indicate that the primary cause of global obesity problem
lies in environmental and behavioral changes. This rapid increase in obesity rate has occurred
in too short a time for them to bring significant genetic changes within populations. The
global obesity problem in children can be viewed as a consequence of massive social,
economic and cultural problems now faced by the developing countries. The increasing
proportion of fat and energy dense foods in the diet and the rise in sedentary behavior
strongly influence the energy balance equation. These are major modifiable factors through
which many of the external forces leading to weight gain act.

Table 1.1 summaries food environment factors hypothesized to increase energy intake and
physical activity environment factors hypothesized to decrease energy expenditure.

McNutt et al (1997) reported higher prevalence of obesity among girls (9-10 years)
consuming fast foods four times or more a week than those who did not. This was due to
consumption of additional 185-260 kcal per day. Ludwig et al (1999 and 2002) reported that
the consumption of meals with high Glycemic Index (Gl) foods induces a sequence of
hormonal events stimulating hunger and cause overeating in adolescents. His study also
showed that the risk of developing obesity in school children increases by 60% for every
additional daily serving of sugar sweetened drinks. Maggie et al (2002) found that children
whose parents scored highest on either dietary restraint (individual’s conscious efforts to
restrict food intake) or disinhibition (impulsive eating) had greater increase in body fat.
Epstein (1995) suggested that obese children are more sedentary than their non-obese
peers and chose to be sedentary when given the option of being active or sedentary. Grieger
(2000) reported that inactivity plays a major role in obesity in children as they spend
considerable time viewing-Television (TV), playing video games and using computer. TV
viewing is associated with the onset of obesity, increases in inactivity levels and may possibly
influence diet (Gortmaker, Dietz and Chung 1990). Robinson (2001) reported that dance
intervention could result in reduction in Body Mass Index (BMI) and improve physical
fitness among girts. According to Jonathan et al (2000) reduction in TV viewing significantly
decreased the measurements of obesity viz. BMI, Waist to Hip Ratio (WHR), Skin Fold
Thickness (SFT) and Waist Circumference (WC) in kids.

The role of genetic factors in weight gain and the discovery of ieptin and the obesity
gene are the current topics of research. Leptin, the hormone product of this gene, is an
important satiety factor secreted by the adipose tissue in humans. Various studies have
identified a region on human chromosome 2 that accounts for variation in serum leptin
concentration and fat mass in population (Ruhl and Everhart 2001).

Psychosocial influences on childhood obesity include personality, coping styles,


perceived barriers, interpersonal skills, parental psychological functioning and body image
(Dorman et al 1995). Interventions between genes and an environment characterised by
energy imbalance due to sedentary lifestyles and ready access to an abundance of food,
results in obesity (Sherwood 2000).

While the basic cause of overweight arid obesity is simply an imbalance between
energy intake and energy expenditure it is in practice a complex condition arising from a
multiplicity of factors viz. genetic, biological, environmental and behavioural factors. Indeed,
obesity may be aptly described as a genetic misfortune, a behavioural gamble in a tempting
environment (Florentino 2002). A downward spiral of development and consequences of
obesity is presented in Figure 1.2.
CONCERNS RELATED TO CHILDHOOD OBESITY

Understanding the trends in childhood obesity is necessary as obesity in childhood has


many adverse effects on health both in childhood and adulthood. Childhood obesity is not a
disease as there are few known physical health risks among children who are obese. The
primary concern for childhood obesity is the subsequent obesity during adulthood, leading to
health problems. Children who are obese are at somewhat increased risk of becoming obese
adults; that is the relative weight and skin fold thickness tend to ‘track’ overtime. The
probability that obesity will persist into adulthood is 50% if the chiid is more than six years of
age, and 70%-80% for an obese adolescent. The presence of obesity in at least one parent
increases the risk of persistence in children at every age.

Sugrimori et al (1999) studied the temporal causes of obesity by tracking 479


Japanese children over 12 years. Among children who were obese at 17 years, most could be
tracked from primary school. The earlier the child was detected to be obese, the greater the
BMI at 17 years of age. The BMI at adolescence was noted to be an important predictor of
adult obesity. Increasingly, obesity is now recognised as a chronic condition, the root of many
other chronic diseases and just should not be dismissed as a weakness of self-discipline and
gluttony. As a result of the global obesity epidemic, many chronic diseases are now appearing
in childhood itself rather than adulthood. Obesity results in physical and psychological
consequences to the affected individual. It also poses a significant economic burden to the
society.

Must et al (1992) concluded that overweight in adolescence increases the mortality


from various Chronic Degenerative Diseases (CDD) such as coronary heart disease, stroke,
colorectal cancer and morbidities such as gout and arthritis.

The Bogalusa heart study among obese individuals between five and twenty four
years of age showed significant clustering of three risk factors for cardiovascular disease,
high systolic blood pressure, high fasting levels of insulin and high ratios of Low Density
Lipoprotein Cholesterol (LDL-C) to High Density Lipoprotein Cholesterol (HDL-C).
Dyslipidemia, hypertension and insulin resistance are frequently seemin obese children. The
incidence of Non Insulin Dependent Diabetes Mellitus (NIDDM) among obese adolescents
increases by 10 times. They have higher fasting blood glucose (FBS) and insulin levels and
abnormal glucose test results (Webber et al 1991).
Bavdekar et al (1999) have shown that totai cholesterol and LDL-C levels are high in
children of low birth weight but with high fat mass at 8 years. The central adiposity is
associated with increased free fatty acids due to lipolysis of visceral fat and increased Very
Low Density Lipoprotein Cholesterol (VLDL-C) and LDL-C synthesis due to
hyperinsulinemia.

Various studies have shown an association between severe childhood obesity and
increased incidence of acute respiratory infections and sleep apnoeas. The obese children are
at increased risk of orthopedic problems such as tibial torsion, bowl bowed legs and slipped
capital femoral epiphysis. They are also prone to skin disorders such as heart rash, intertrigo,
monoleal dermatitis and Acanthosis nigercans (WHO 2000).

Obesity can have very significant psychological consequences. Stafferi et al (1967)


reported children only six years of age who labeled silhouettes of an overweight child as lazy,
dirty, stupid and ugly. Bruche (1975) described the psychological consequences of obesity in
children. According to him fat in excess in children is a sad thing. They are bashful and
ashamed of their shapeless obesity can have very significant psychological consequences.
Stafferi et al (1967) reported children only six years of age who labeled silhouettes of an
overweight child as lazy, dirty, stupid and ugly. Bruche (1975) described the psychological
consequences of obesity in children. According to him fat in excess in children is a sad thing.
They are bashful and ashamed of their shapeless figures yet unable to conceal them. They
attract attention wherever they go. Obesity is a serious handicap in the social life of a child
more so for a teenager. Loke (2002) discussed the detrimental consequences of poor self-
esteem, which includes significantly increased rates of sadness, loneliness and nervousness in
obese adolescence compared to non-obese children. These obese children are more likely to
engage in high-risk behaviours such as smoking and alcohol consumption. He also pointed
out that for obese children, adolescence and adults, there is the burden of direct medical cost
covering the cost of prevention, diagnosis and treatment. There are also indirect costs that
refer to the value of low output through the cessation of productivity, caused by morbidity
and mortality. Wang (2000) concluded that among all hospital discharges in youth from six to
seventeen years of age, the proportion of discharge with obesity associated disease had
increased dramatically in the past twenty years in US. These findings reflect the impact of an
increased prevalence and severity of obesity. The obesity associated annual hospital cost had
increased more than three fold.
Obesity is leading cause of pediatric hypertension and a known risk factor for adult obesity.
Thus obesity causes a great loss of quality of life and suffering both to the patients and to
their families.

PREVALENCE OF OBESITY IN CHILDREN

Over the past century most nutrition research and policies concerning the developing
world was focused and restricted to poverty and undernutrition. However, now there is a
significant swing towards research on overweight and obesity in these societies in all age
groups. According to WHO, the global prevalence of overweight and obesity has reached
epidemic proportion. Many studies have documented the increase in overweight among
adults. Recently, De Onis et al (2000) and Matoate et al (2000) examined obesity in preschool
children from developing countries. There are several reports discussing the rapid increase in
childhood obesity in higher income countries. Apart from this large global prevalence, two
other features make this picture even more alarming, rapidly increasing prevalence in the last
decade and increasing prevalence of overweight and obesity among children.

In the US since the 1960s large nationally representative surveys have assessed the
prevalence of obesity in children. The National Health Examination Surveys (NHES) I, II and
III have observed the prevalence of obesity to be 25%-30% percent. The surveys found that
the Hispanics, Native Americans and Black population were more affected. The estimations
from Canada showed that childhood obesity ranged from 7%-43%. The condition is more
common among Native Canadians. A national survey in Britain in 1974 showed that 7.3% of
thes# children and adolescents between 7-16 years of age were obese. In Japan, between 1974
and 1993, the prevalence of obese school children increased from 5%-10%. Kromeyear and
Hauschild et al (1999) reported the increase in prevalence of obesity in German school
children during 1975-1995 from 5%-8% in boys and from 4%-10% in girls. In Thailand, it
rose from 12.7% in 1991 to 15.6% in 1993. In Saudi Arabia it was 15.8% among males from
6-18 years of age (WHO 2000). Table 1.2 presents the global scenario of overweight and
obesity in children.

INDIAN SCENARIO

The developing countries in Southeast Asia are in a state of socio-economic transition in


which under nutrition co-exists with nutrition. In some countries under nutrition
predominates among children, while in other countries the rising prevalence of obesity among
children is of greater concern. Nationally representative data are not available from India.
However, school based studies from middle income schools have shown that about 10% of 8-
16 years old children are obese. In a study of school children from 9-12 years of age,
prevalence of obesity was 5.6% (Yadav 2002). Jayshree (2001) reported the prevalence of
obesity in preadolescent children as 16.3% and 2.8% in adolescents. A study carried out by
Singh (2000) on affluent school children (10-16 years) of Delhi showed the prevalence of
obesity as 13.4%. Table 1.3 summaries the available prevalence data on school children of
India.

At regional level, under the guidance of Prof. U. V. Mani, at the Department of Foods
and Nutrition, M. S. University of Baroda, Vadodara, a series of studies in the area of adult
obesity were undertaken (Table 1.4). The magnitude of the problem of overnutrition in adult-
population is a matter of concern. However, few efforts have been made to map the
prevalence of overweight and obesity among older children and adolescence of Gujarat,
India. Most recent studies carried out to map the prevalence in school children of urban
Vadodara (Table 1.5) have shown an increasing prevalence of overweight and obesity.

DEFINING OVERWEIGHT AND OBESITY IN CHILDREN

Anthropometry is one of the most basic tool for assessing nutritional status, be it under
nutrition or over nutrition. There are a number of methods available to measure body fatness
and body thinness. Some of the most commonly used techniques for their accurate
estimations are under water weighing, Dual energy X Ray Absorptiometry (DXA), total body
water, total body electric conductivity, total body potassium and computed tomography. The
use of most of these methods is restricted to research setting only on account of their
complexity and cost. The direct estimation of fat and free fat mass is very challenging, more
so because it is influenced by age and state of maturation. Out of these only a few techniques
are useful for children. The most frequently used tool in public health evaluations and clinical
screening or school settings are anthropometric based measurements such as skin fold
thickness, circumference measurements or various height and weight based indices such as
weight for height, BMI and Rohrer Index.

Skin fold thickness is a more precise measure of adiposity. However, the


comparability across cross section surveys is less consistent and standard data are not
internationally available for children and adolescents. The BMI measured as weight
(kg)/height (m2), has become the most desirable index for diagnosis of obesity. The BMI
curves have been generated for children for a number of countries such as US, Britain and
Sweden. International Obesity Task Force (IOTF) have recommended Cole et al Standards
(2000) which are based on BMI extrapolated for age and gender specific cut off points to
classify overweight and obesity in children (2-18 years).

The Evaluation of obesity in children is invaluable since it offers paramount prospects


for preventing its progress with its associated morbidities into adulthood. However defining
obesity or overweight for children and adolescents is difficult for want of consistency and
agreement between different methods used for their classification. The height and weight
measures can be obtained with a reasonable accuracy in a variety of settings including field
studies, clinical practice and research. Hence weight status based on height and weight is
commonly used for classification. They are one of the most practical tools for assessing the
nutritional status on account of their simplicity and low cost. Of these methods, BMI is most
widely used and recommended for classifying overweight and obesity.

The studies carried out on indicators of obesity to be used for children suggested that
the age and sex specific BMI cut off values proposed by Cole et al (2000) and Must et al
(1991) can be used for the prevalence of obesity in children (Abrantes et al 2002). Mei et al
(2002) concluded that the performance of BMI for age is better than Rohrer index {wt
(kg)/ht(cm3)} for age in predicting underweight and overweight. Khadgwat et al (1998)
suggested that Agarwai charts based on Indian affluent school children are better
representative of the growth of normal Indian children than Indian Council of Medical
Research (ICMR) or National Council for Health Statistics (NCHS) standards.

WC is now accepted as one of the practical measures of adipose tissue distribution


(Wang et al 2003). He highlighted that the WC measurements are increasingly being
promoted as a part of clinical obesity evaluation. Dasgupta and Hazra (1999) concluded that
WC is simple to assess and can be used as an independent measurement to identify those at
risk from either increased body weight or central fat distribution or both. Clasey et al (1999)
and Lean et al (1996) found that WC measured at the narrowest point of the torso is a strong
predictor of total adipose tissue and visceral adipose tissue (VAT) measured with computed
tomography. The cut off values for the indicators of obesity are listed in Table 1.6.
Fu et al (2003) concluded that IOTF recommended BMI cut off values had lower
sensitivity and may underestimate the local prevalence of childhood obesity. For screening
purpose, population specific measures rather than international cut off values should be used.
Gei et al (2001) concluded that in prepubescent children, height to weight indices such as
BMI or Ponderal Index (PI) could predict cardiovascular risk factors better than SFT. The
BMI may be superior to PI as the association between BMI and Cardiovascular Disease
(CVD) is less affected by gender.

WHO experts hayed recommended that thinness as well as obesity should be


evaluated by body ponderosas indices particularly BMI and SFT. It has been recommended
that 85th percentile of BMI should be considered as cut off point for overweight and greater
than 95th percentile for defining obesity for its association with height and other morbidities
in children. Daniel (2000) demonstrated that WC was one of the simple measures of fat
distribution as it was least affected by gender, race and overall adiposity. Moreover WC is
easy to determine and is a useful measure of fat distribution for children and adolescents.

From the view of public health importance the trends in childhood obesity should be
closely monitored. Trends are however difficult to quantify or to compare internationally as a
wide variety of definitions of childhood obesity are in use and there are no commonly
accepted standards. The ideal definition based on percent body fat is impracticable for
epidemiological use. Clearly a cut off point reflected to age and sex is needed to define
childhood obesity, which is based on adult cut off points for overweight and obesity (Cole et
al 2000).

From the current literature it is clear that the global epidemic of overweight and
obesity is at our doorstep. The emerging problem of overweight and obesity in children is a
matter of growing concern. Several reports have shown the increasing the increasing rates of
obesity in developed countries whereas the magnitude of the problem in India and regional
context remains relatively unknown. The foremost is the paucity of national and regional
prevalence and epidemiological data on overweight and obesity in children and adolescents.

Therefore the present study was planned to find the magnitude and trends of
overweight and obesity amongst school children of urban Vadodara in western part of
Gujarat, India and to identify the risk factors associated with it.
THE SPECIFIC OBJECTIVES OF THE STUDY WERE:

1. To assess the prevalence of overweight and obesity in school children (12-17 years) of
urban Bareilly.
2. To study the correlation between energy intake and energy expenditure in children.
3. To investigate the effect of lifestyle factors including dietary practices and activity
pattern on the prevalence of obesity.
4. To assess the metabolic aberrations with respect to lipid profile in overweight and
obese children.
5. To develop age and sex specific BMI percentile curves.
CHAPTER 2
REVIEW OF LITERATURE
A literature review can be defined as the selection of available documents (both published
and untpublished) on the topic, which contain information, ideas, data and evidence written
from a particular standpoint to fulfil certain aims or express certain views on the nature of the
topic and how it is to be investigated, and the effective evaluation of these documents in
relation to the research being proposed (Hart, 1998). According to Bruce (1994) "Typically,
the literature review forms an important chapter in the thesis, where its purpose is to provide
the background to and justification for the research undertaken.” The purpose of the literature
review is to locate the research project, to form its context or background, and to provide
insights into previous work (Blaxter et al., 2006).
In this study, the different aspects of the overweight students such as selected components of
weight an fat related variables has been studied. In order to study these aspects thoroughly the
literature has been divided into four parts. In the first part studies related to aerobics related
research review, in second part studies related to Swiss ball and pilates exercise related
research , in third part gymnastics effect to weight and fat component and in the third four
part the studies related to aquatics exercise effect to weight and fat related research have been
covered.
REVIEW OF RELATED LITERATURE OF AEROBICS EXERCISE
REHABILITATION PROGRAM
Heijden50 have pointed out that research background: Exercise might have a persistent effect
on energy expenditure and fat oxidation, resulting in increased fat loss. However, even
without weight loss, exercise results in positive metabolic effects. The effect of an aerobic
exercise program on 24-h total energy expenditure (TEE) and its components—basal (BEE),
sleep (SEE), and awake sedentary (SEDEE) energy expenditure and substrate oxidation—has
not been studied in lean and obese adolescents. Objective: The objective was to test the
hypothesis that 24-h energy expenditure and fat oxidation increase in lean and obese
adolescents after 12 wk of moderate aerobic exercise without dietary intervention and weight
loss. Design: Twenty-eight post pubertal Hispanic adolescents (13 lean [mean ± SE: age, 15.3
± 0.3 y; body mass index (BMI; in kg/m2), 20.2 ± 0.7; body fat, 18.7 ± 1.6%] and 15 obese
[age, 15.6 ± 0.3 y; BMI, 33.1 ± 0.9; body fat, 38.1 ± 1.4%]) completed a 12-wk aerobic
exercise program (4 × 30 min/wk at ≥70% of VO2 peak) without weight loss. Energy
expenditure and substrate oxidation were quantified by 24-h room calorimeter at baseline and
post exercise. Results: This aerobic exercise program did not affect 24-h TEE, BEE, SEE, or
SEDEE in lean or obese participants. In obese adolescents, respiratory quotient (RQ) and
substrate oxidation also did not change. In lean adolescents, 24-h RQ and RQ during SEE
decreased (both P < 0.01) and fat oxidation increased (P < 0.01).Conclusions: A 12-wk
aerobic exercise program did not increase TEE, BEE, SEE, or SEDEE in either lean or obese
sedentary adolescents. Furthermore, 24-h fat oxidation did not change in the obese
adolescents, whereas it increased in the lean adolescents
50 Faigenbaum51 reported that the prevalence of obesity among children and adolescents is
increasing at an alarming rate. If current trends continue, this epidemic will likely pose an
unprecedented burden on youth, their families and our health care system. It is important to
understand how sensible lifestyle choices such as regular exercise can enhance the health and
well-being of obese children and adolescents. While aerobic exercise has traditionally been
recommended for obese youth, a growing body of scientific evidence indicates that resistance
training can be a safe, effective, and enjoyable method of exercise provided that appropriate
training guidelines are followed and qualified instruction is available. In addition to
favourable changes in body composition, regular participation in strength-building activities
gives obese youth a chance to experience success, feel good about their performances, and
gain confidence in their abilities to be physically active. Moreover, participation in resistance
exercise gives youth with a high percentage of body fat a chance to be exposed to a form of
exercise that can be carried over into adulthood. In this paper, we will discuss the potential
benefits of resistance training for obese youth and describe program design considerations for
designing resistance training programs for obese children and adolescents.
The prevalence of obesity during childhood and adolescence has reached epidemic
proportions worldwide.41, 52 This unabated epidemic is occurring in boys and girls across all
socioeconomic strata and it appears that obese children and adolescents are at high risk for
becoming obese adults.14, 27, 29, 31 These trends have led some observers to predict that the
overall adult life expectancy will decrease due to the increased prevalence of obesity-related
co-morbidities such as type 2 diabetes, cardiovascular disease and cancer.40 Today,
childhood obesity, with its associated co-morbid conditions and its likelihood of persistence
into adulthood, is considered a critical public health threat for the 21st century.29, 31
Learning how sensible lifestyle choices, such as regular exercise, can improve the body
composition and enhance the health and well-being of obese children and adolescents is a
growing area of interest among health and physical education teachers, researchers, health
care providers, and government officials. While both normal weight and obese youth have
traditionally been encouraged to participate in aerobic activities such as walking and cycling,
over the past two decades a compelling body of evidence has accumulated to indicate that
resistance training can be a safe, effective and beneficial method of exercise for all youth
regardless of body size.24, 38, 54 Research into the effects of resistance exercise on normal
weight and obese children and adolescents has increased over the years, and the qualified
acceptance of youth resistance training by medical and fitness organizations has become
almost universal.1, 3, 6, 16 This paper discusses the potential benefits of youth resistance
training and provides program design considerations for developing resistance training
programs for obese children and adolescents. For the purpose of this paper, the term “obese”
refers to youth (both children and adolescents) with a body mass index (BMI [weight in
kg/height in m2]) equal to or greater than the 95th percentile of the age- and gender-specific
BMI distribution.35 The term “at risk for obesity” is defined as a BMI at or above the age-
and gender-specific 85th percentile but less than the 95th percentile. The term “resistance
training” is defined as a specialized method of physical conditioning that involves the
progressive use of a wide range of resistive loads and a variety of training modalities to
increase one’s ability to exert or resist force. The term “children” refers to boys and girls who
have not yet developed secondary sex characteristics (approximately age 11 in girls and 13 in
boys) and the term “adolescence” refers to the period between childhood and adulthood and
includes girls 12 to 18 years and boys 14 to 18 years.

Stasiulis52 examined that the objective of the study was to assess changes in body
composition, blood lipid and lipoprotein concentrations in 18-24-year-old women during the
period of two-month aerobic cycling training. Material and Methods: Young, healthy, non-
smoking women (n=19) volunteered to participate in this study. They were divided in two
groups: experimental (E, n=10) and control (C, n=9). The subjects of group E exercised 3
times a week with intensity of the first ventilator threshold and duration of 60 min. The group
C did not exercise regularly over a two-month period of the experiment. The subjects of
group E were tested before and after 2, 4, 6 and 8 weeks of the experiment. The participants
of group C were tested twice with an eight-week interval. Results: Body weight, body mass
index, body fat mass, and triacylglycerol (TAG) concentration decreased and high-density
lipoprotein cholesterol (HDL-ch) concentration increased after the 8-week training program
in the experimental group (P<0.05). Blood total cholesterol and low-density lipoprotein
cholesterol (LDL-ch) concentrations did not change significantly. Body weight and body
mass index started to decrease after 2 weeks of the experiment, but significant changes were
observed only after 6 and 8 weeks. Body fat mass was significantly decreased after 2 and 8
weeks of aerobic training. A significant increase in HDL-ch concentration was observed after
4, 6, and 8 weeks. A significant decrease in TAG concentration was observed after 2-week
training. No significant changes in all the parameters except TAG (it was slightly increased)
were seen in the control group. Conclusions: The two-month aerobic cycling training (within
VT1, 60-min duration, three times a week) may induce significant changes in the parameters
of body composition--body weight, body mass index, body fat mass, and blood lipids--in
young women. The following significant changes were observed: TAG level decreased after
2 weeks, body mass and body mass index decreased after 6 weeks, body fat mass decreased
and HDL-ch level increased after 8 weeks. Peak oxygen uptake increased after 4 weeks.
Atlantis53 determined the overweight prevalence among children/adolescents is increasing,
while adult obesity may potentially cause a decline in life expectancy. More exercise is
uniformly recommended, although treatment efficacy remains unclear. Objective: To
determine the efficacy of exercise alone for treating overweight in children/adolescents.
Design: A systematic review and meta-analysis of randomized trials published in English
were completed following multiple database searches performed on December 10, 2004.
Studies of isolated or adjunctive exercise/physical activity treatment in overweight/obese
children or adolescents which reported any overweight outcome were included. Literature
searches identified 645 papers which were manually searched, of which 45 were considered
for inclusion, of which 13 papers which reported 14 studies were included (N=481
overweight boys and girls, aged 12 years). Two reviewers independently identified relevant
papers for potential inclusion and assessed methodological quality. Principal measures of
effects included the mean difference (MD) (between treatment and control groups), the
weighted MD (WMD), and the standardized MD (SMD). Results: Few studies were of robust
design. The pooled SMD was -0.4 (-0.7, -0.1, P=0.006) for percent body fat, and -0.2 (-0.6,
0.1, P=0.07) for central obesity outcomes, whereas the pooled WMD was -2.7 kg (-6.1 kg,
0.8 kg, P=0.07) for body weight, all of which favoured exercise. Pooled effects on body
weight were significant and larger for studies of higher doses, whereas non significant and
smaller effects were seen for studies of lower doses of exercise (155–180 min/weeks vs 120–
150 min/weeks) Conclusions: Based on the small number of short-term randomized trials
currently available, an aerobic exercise prescription of 155–180 min/weeks at moderate-to-
high intensity is effective for reducing body fat in overweight children/adolescents, but
effects on body weight Stasiulis52 examined that the objective of the study was to assess
changes in body composition, blood lipid and lipoprotein concentrations in 18-24-year-old
women during the period of two-month aerobic cycling training. Material and Methods:
Young, healthy, non-smoking women (n=19) volunteered to participate in this study. They
were divided in two groups: experimental (E, n=10) and control (C, n=9). The subjects of
group E exercised 3 times a week with intensity of the first ventilator threshold and duration
of 60 min. The group C did not exercise regularly over a two-month period of the experiment.
The subjects of group E were tested before and after 2, 4, 6 and 8 weeks of the experiment.
The participants of group C were tested twice with an eight-week interval. Results: Body
weight, body mass index, body fat mass, and triacylglycerol (TAG) concentration decreased
and high-density lipoprotein cholesterol (HDL-ch) concentration increased after the 8-week
training program in the experimental group (P<0.05). Blood total cholesterol and low-density
lipoprotein cholesterol (LDL-ch) concentrations did not change significantly. Body weight
and body mass index started to decrease after 2 weeks of the experiment, but significant
changes were observed only after 6 and 8 weeks. Body fat mass was significantly decreased
after 2 and 8 weeks of aerobic training. A significant increase in HDL-ch concentration was
observed after 4, 6, and 8 weeks. A significant decrease in TAG concentration was observed
after 2-week training. No significant changes in all the parameters except TAG (it was
slightly increased) were seen in the control group. Conclusions: The two-month aerobic
cycling training (within VT1, 60-min duration, three times a week) may induce significant
changes in the parameters of body composition--body weight, body mass index, body fat
mass, and blood lipids--in young women. The following significant changes were observed:
TAG level decreased after 2 weeks, body mass and body mass index decreased after 6 weeks,
body fat mass decreased and HDL-ch level increased after 8 weeks. Peak oxygen uptake
increased after 4 weeks.
Atlantis53 determined the overweight prevalence among children/adolescents is increasing,
while adult obesity may potentially cause a decline in life expectancy. More exercise is
uniformly recommended, although treatment efficacy remains unclear. Objective: To
determine the efficacy of exercise alone for treating overweight in children/adolescents.
Design: A systematic review and meta-analysis of randomized trials published in English
were completed following multiple database searches performed on December 10, 2004.
Studies of isolated or adjunctive exercise/physical activity treatment in overweight/obese
children or adolescents which reported any overweight outcome were included. Literature
searches identified 645 papers which were manually searched, of which 45 were considered
for inclusion, of which 13 papers which reported 14 studies were included (N=481
overweight boys and girls, aged 12 years). Two reviewers independently identified relevant
papers for potential inclusion and assessed methodological quality. Principal measures of
effects included the mean difference (MD) (between treatment and control groups), the
weighted MD (WMD), and the standardized MD (SMD). Results: Few studies were of robust
design. The pooled SMD was -0.4 (-0.7, -0.1, P=0.006) for percent body fat, and -0.2 (-0.6,
0.1, P=0.07) for central obesity outcomes, whereas the pooled WMD was -2.7 kg (-6.1 kg,
0.8 kg, P=0.07) for body weight, all of which favoured exercise. Pooled effects on body
weight were significant and larger for studies of higher doses, whereas non significant and
smaller effects were seen for studies of lower doses of exercise (155–180 min/weeks vs 120–
150 min/weeks) Conclusions: Based on the small number of short-term randomized trials
currently available, an aerobic exercise prescription of 155–180 min/weeks at moderate-to-
high intensity is effective for reducing body fat in overweight children/adolescents, but
effects on body weight sedentary obese women. Type of study: This study comprised an
eight-week randomised controlled trial. Methods: A total of 49 healthy sedentary obese
women participated in this study voluntarily. They were randomly divided into two groups:
those undertaking a step-aerobic dance exercise programme (n=29) and a control group
(n=20). The subjects too part in a step-aerobic dance exercise programme for one hour per
day, three days a week for eight weeks. The subjects' Body Mass Index (BMI), weight, waist
circumference, waist-hip ratio, four-site skin fold thickness, fat percentage, basal metabolic
rate and lean body mass were assessed before and after the completion of the step-aerobic
dance exercise programme. Results: After the eight weeks of the step-aerobic dance exercise
programme, significant differences were found in the subjects' weight, BMI, body
composition parameters, waist-hip ratio (WHR), waist circumference (WC), fat percentage,
lean body mass (LBM) and basal metabolic rate (BMR) in the experimental group (p<0.05).
There were no significant differences in the control group after the experiment in terms of the
same measures (P>0.05). Conclusion: The step aerobic dance programme proved to be a
useful exercise modality for weight loss and in terms of body composition. There was a clear
response to the eight-week step aerobic dance programme in terms of central obesity in
sedentary obese Turkish women.
Leslie H. Willis et al58 made a comparison the recent guidelines on exercise for weight loss
and weight maintenance include resistance training as part of the exercise prescription. Yet
few studies have compared the effects of similar amounts of aerobic and resistance training
on body mass and fat mass in overweight adults. STRRIDE AT/RT, a randomized trial,
compared aerobic training, resistance training, and a combination of the two to determine the
optimal mode of exercise for obesity reduction. Participants were 119 sedentary, overweight
or obese adults who were randomized to one of three 8-mo exercise protocols: 1) RT:
resistance training, 2) AT: aerobic training and 3) AT/RT: aerobic and resistance training
(combination of AT and RT). Primary outcomes included total body mass, fat mass and lean
body mass. The AT and AT/RT groups reduced total body mass and fat mass more than RT
(P < 0.05), but they were not different from each other. RT and AT/RT increased lean body
mass more than AT (P < 0.05). While requiring double the time commitment, a program of
combined AT and RT did not result in significantly more fat mass or body mass reductions
over AT alone. Balancing time commitments against health benefits, it appears that AT is the
optimal mode of exercise for reducing fat mass and body mass, while a program including RT
is needed for increasing lean mass in middle-aged, overweight/obese individuals.
Patricia CH Wong et al59 have pointed out that introduction: Developing effective exercise
programmes for the paediatric population is a strategy for decreasing obesity and is expected
to help in eventually limiting obesity-associated long-term health and societal impact. In this
study, the effects of a 12-week twice weekly additional exercise training, which comprised a
combination of circuit-based resistance training and aerobic exercises, in additional to typical
physical education sessions, on aerobic fitness, body composition and serum C-reactive
protein (CRP) and lipids were analyzed in 13- to 14-year-old obese boys contrasted with a
control group. Materials and Methods: Both the exercise group (EG, n = 12) and control
group (CG, n = 12) participated in the typical 2 sessions of 40-minute physical education
(PE) per week in schools, but only EG participated in additional 2 sessions per week of 45 to
60 minutes per session of exercise training, which comprised a combination of circuit-based
resistance training and aerobic exercises maintained at 65% to 85% maximum heart rate
(HRmax = 220 - age). Body composition was measured using dual energy X-ray
absorptiometry (DEXA). Fasting serum CRP and blood lipids were analyzed pre- and post
exercise programme. Aerobic fitness was measured by an objective laboratory sub-maximal
exercise test, PWC170 (Predicted Work Capacity at HR 170 bpm). Results: Exercise training
significantly improved lean muscle mass, body mass index, fitness, resting HR, systolic blood
pressure and triglycerides in EG. Serum CRP concentrations were elevated at baseline in both
groups, but training did not result in a change in CRP levels. In the CG, body weight
increased significantly at the end of the 12-week period. Conclusion: This study supports the
value of an additional exercise training programme, beyond the typical twice weekly physical
education classes, to produce physiological benefits in the management of obesity in
adolescents, including prevention of weight gain.
Vivek G. Awasare60 examined the main purpose of the study was to see the effect of
aerobics exercises on physical fitness and body composition of school boys. The selected 40
student were equally divided into two equal groups consisting 20 subjects in each group
assigned in experimental and control groups. The pre and post test were significantly different
saw on conducted on the physical fitness variables, abdominal strength, speed and
cardiovascular endurance and body composition.
Sofien Regaieg et al61 conducted the background: The prevalence of children obesity is
raising alarmingly in both developed and developing countries developing effective exercise
programs are a strategy for decreasing this prevalence and limiting obesity-associated long-
term comorbidities. Objectives: To determine whether 16-week training program; in addition
to the school physical education and without dietary intervention; could have beneficial
effects on body composition and aerobic capacity of obese children. Materials and Methods:
Twenty-eight obese children (16 boys, 12 girls; aged 12-14 years) were enrolled and were
divided into either the exercise group (EG, n = 14) or the control group (CG, n = 14). EG
participated in a 16-week aerobic exercises (four 60-min sessions per week at 70-85% of
HRmax (maximum heart rate)), in addition to the school physical education. Fat-Free Mass
(FFM) and Fat Mass (FM) were assessed with bioelectrical impedance equipment. To assess
aerobic capacity, maximal metabolic equivalent of task (MET-max) and maximal workload
(W-max) were estimated with an electronically braked cycle ergo meter (type Ergo line 500).
Results: At baseline, there were no differences between the two groups. After the training
program, only the EG showed significant reduction in BMI (body mass index) and waist
circumference compared with the baseline values (P < 0.001). Exercise training significantly
decreased FM only in the EG. A significant increase in FFM was seen in both groups; more
marked in the EG. There was a significant increase in MET-max (P < 0.05) and W-max (P =
0.02) in the EG, and no significant changes in these parameters were seen in the CG. HRmax
significantly decreased only in the EG (P < 0.05). Conclusion: This training program has
beneficial effects on body composition and aerobic capacity parameters in obese children.
Our intervention has the advantage of providing a sustainable and reproducible school and
community approach for the management of children obesity.
Marra C et al62 studied the effect of Moderate and High Intensity Aerobic Exercise on the
Body Composition of Overweight. The optimal aerobic exercise training intensity to improve
body composition in overweight men is unclear. The purpose of this study was to determine
the effect of 14 weeks of high intensity versus moderate intensity aerobic exercise of equal
work output on body composition in overweight men (BMI = 25-29.9 kg/m2). Sixteen
sedentary military men (18 - 33 yrs) were randomized in two equal groups (n=8): 1) moderate
intensity exercise (MI; 60 - 70% of their maximum heart rate; HRmax), and 2) high intensity
exercise (HI; 75 - 90% HRmax) The aerobic exercise (jogging/running) training program was
performed three days/wk. Relative body fat (% BF) was assessed by dual energy x-ray
absorptiometry (DXA) (Lunar DPX - IQ). Significant differences between and within the
groups were analyzed using a two-way split-plot analysis of variance (SPANOVA).
Statistical significance was accepted at p<0.05. After the 14 wks of the aerobic exercise
program the mean %BF of the HI significantly (p<0.05) decreased to 22.49 % (Δ=4.91%).
The decrease in mean %BF (Δ=1.4 %) in the MI was not significant (p>0.05). It is concluded
that 14 wks of HI aerobic exercise may be more effective in improving body composition
than MI aerobic exercise in overweight young military men with physical characteristics
similar to the present study.
Pantelic Sasa et al.63 investigation the aim of this study was to determine the effects of a
twelve-week aerobic dance-training program on the body composition parameters of young
women. The sample of 59 young women belonged to one of two groups, an experimental
(EXP) or a control (CON) group. The experimental group consisted of 29 assess body
compositions, the following measures were used: the overall sum of the upper body skin
folds, the overall sum of the lower body skin folds, the overall sum of skin folds of the upper
and lower body, the percentage of body fat, the percentage of muscle mass in the body, body
height and body weight. For all of the sums of skin folds for the subjects of the EXP group,
we noted a statistically significant decrease (p< 0.05) at the final measuring in relation to the
initial measuring (SFUPPER - 39.35 mm compared to 42.87 mm; SFLOWER - 39.35mm
compared to 49.88 mm; TOTAL SF - 76.97 mm compared to 92.75 mm). In the case of BF%,
a decrease was noted at the final measuring in relation to the initial one (20.37% compared to
22.66%), which was statistically significant (p< 0.05). On the basis of our results, we can
conclude that aerobic dance decreases subcutaneous fatty tissue and body composition of the
young women.
Sohaily Shahram64 examined the Obesity increases the risk of various diseases. Leptin and
insulin are hormones that are involved in regulating and balancing body weight and obesity.
This research aims to explore the impact of intermittent exercise on serum concentration of
leptin and insulin resistance in overweight female students. For this purpose, 30 female
overweight volunteer students (BMI ≥ 26) of Azad University Parand Campus were selected
and randomly divided into two groups: intermittent training group and control group.
Training groups exercised for 12 weeks, three sessions a week with definite intensity and
distance. Leptin, insulin, glucose, body weight, fat percentage, BMI And maximum oxygen
consumption were measured both before and after the 12-week exercise. Using Independent
T-test, the results showed that interval training had significant effect on leptin, insulin
resistance index, body weight, fat percentage, BMI and maximum oxygen consumption (p ≤
0.05). Therefore our findings support the hypothesis that intermittent exercise leads to
significant decrease of leptin levels and insulin resistance.

Song J K65 reported that the Aim: This study tested the hypothesis that 12 weeks of air board
exercise would enhance cardio respiratory fitness and vascular compliance and reduce %
body fat in obese Korean boys. Methods: Twenty-two obese boys (>30% body fat) were
studied. They were divided into 2 groups- an aerobic exercise group (N.=12), which trained 3
days/week, 50 min/day for 12 weeks, and a control group (N.=10). Control subjects only
performed activities involved in their physical education classes. Body composition,
cardiovascular fitness (20 m multistage endurance test performance) and vascular compliance
were assessed before and after the completion of exercise training. Results: The % changes in
body fat (-4.6±0.9 vs. -1.5±1.0%), fat mass (-5.4±1.5 vs. -0.1±1.6%) and performance on the
cardiovascular fitness test (14.3±2.5 vs. 3.7±1.6%) were greater in the exercise group than in
the controls Compared to controls, % increases in vascular compliance were greater in the
arms and legs of the exercise group (left arm: 2.8±0.5 vs. 2.0±2.9%; left leg: 2.6±1.2 vs. -
0.5±2.0%; right arm: 2.9±0.9 vs. 0.3±2.9%; right leg: 4.8±1.8 vs. 1.5±2.0%). Conclusion:
Results suggest that exercise training can reduce % body fat and enhance vascular
compliance in obese male adolescents; changes that may reduce the risk for later
development of cardiovascular disease.

Kelly Kalovcak 66 considered the Childhood obesity is a significant public health problem,
and school-based interventions offer opportunities to reach children. We examined the
feasibility of using stability balls, as compared to traditional desk chairs, in elementary school
classrooms testing effects on vital signs and BMI. Forty-seven fourth graders from two
classrooms participated: twenty-seven using balls and 20 using chairs over a 45 day period
from the beginning to the end of the second quarter of school. Overall, children welcomed
using stability balls and over 90% reported improvement of the classroom’s learning
environment. No significant difference was found in BMI percentile (p = 0.726), systolic (p =
0.148) or diastolic (p = 0.747) blood pressure percentiles, or resting pulse (p=0.977) between
the two classrooms.
Aarti Welling and Peeyoosha Nitsure67 have pointed out that the background & objective:
Obesity refers to a condition of having excessive amount of body fat. Not only the amount of
excess fat needs to be considered but where in the body it is distributed is also of importance.
The intra-abdominal fats carry a greater health risk than that stored elsewhere in the body.
Various exercises have been designed for obesity but in particular the exercises designed for
abdomen are using mat, Swiss ball and theraband exercises. However, there is dearth in
literature as to indicate which of the 3 is better and more effective. Hence, the study was
conducted with the objective to study the comparative effect of 5 week training program
between Mat, Swiss ball and theraband exercises on abdominal girth and skin fold thickness.
Methods: Sixty healthy individual aged18 to 40 years were randomly assigned to all of 3
groups. Mat (n=20), Swiss ball (n=20) and theraband (n=20). Pre and post assessment was
done using BMI, waist circumference, waist hip ratio and abdominal skin fold thickness.
Results: Within group analysis in all the three groups showed statistically significant
reduction in all outcome (p<0.001).Between groups analysis showed no significant difference
between the 3 groups. Conclusion: The results reflected that 5 week exercise program on mat,
swiss ball and theraband are equally effective in reducing abdominal fat.
Kulroop Kaur Badwal; Ranjit singh68 investigation the purpose of this study was to explore
the effect of short-term swiss ball training on aerobic capacity, body composition and upper
body strength & endurance. For the purpose of the present study, twenty four (N = 24) male
subjects between the age group of 18-27 years (Mean ± SD: age 23.29 ± 2.15 years,
height 1.62 ± 0.021 m, body mass 56.75 ± 4.24 kg) were selected as subjects. The subjects
were purposively assigned into two groups: Group-A: Experimental (N1 = 12) and Group-B:
Control (N2 = 12). The subjects from Group-A were subjected to 4-week of Swiss ball
training. The training consisted of a variety of exercises (i.e., Pelvic Tilt, Abdominal Crunch,
Supine Bridge and Roll, Squat). It is concluded that the aerobic capacity, body composition
and upper body strength and endurance significantly improved in experimental group
compared with the control one. Student's t-test for independent data was used to assess the
between-group differences and for dependent data to assess the Post-Pre differences. In all the
analyses, the 5% critical level (p â ½0.05) was considered to indicate statistical significance.
The swiss ball exercises training may be recommended to improve aerobic capacity, body
composition and upper body strength and endurance to enhance physical fitness based
performance.
Gulsum Bastug et al.69 determined the purpose of this study was to investigate body
composition and body image of women doing Cross-Fit, Pilates and Zumba exercises.
Material and Methods: This study was carried out to investigate body composition and body
areas satisfaction of women doing Cross-Fit, Pilates and Zumba exercises, 80 women
voluntarily being in an average age of 42.74±8.47 voluntarily participated in the research.
The women were grouped into two such as experimental (n=45) and control (n=35). The
women in experimental group were applied 30-70min mixed exercises (Cross-Fit, Plates,
Zumba) for 4 days in a week throughout 12 weeks to have target heart rate of 50-60%.
Results: A significant difference was found between body weight and BMI pre-test and post-
test values of women who were applied mixed exercise program (Cross-Fit, Pilates, Zumba).
There was a decrease in both body weight and average means of BMI of women. A
significant difference was found between body areas satisfaction pre-test and post-test values
of women who were applied Cross-Fit, Pilates, Zumba exercise program. While pre-test value
of body areas satisfaction of women who were applied mixed exercise program was
determined as 31.68±6.11, its post-test value was 35.68±5.02. It is remarkable that while
body weight and BMI of women doing exercises decreased, their body areas satisfaction
values increased. It was indicated that the body areas satisfaction of women having weight
loss increased. A significant difference was not found between body weight, BMI and body
areas satisfaction pre-test and post-test values of women in control group. Conclusion: It was
concluded that there were positive effects on body weight, BMI and body image.
Aruna Raj A and Pramod K G.70 investigation the purpose of these study 135 female hostel
students were tested body composition by using Tanita body composition Analyzer from
Pondicherry University; from that group 54 students were selected on the basis of fat free
mass. Their age ranged from 19 to 25 years. The selected 54 subjects were divided into three
equal groups, two experimental groups and one control group each group consisting of 18
subjects. Experimental group I underwent Yogasana practice, group II underwent Swiss ball
training and group III act as control group who did not participated any training program
except their daily routine. The training program schedule was one session in the evening
between 6.00 pm to 7.00 pm for five days per week for the period of twelve weeks. The yoga
program includes prayer, loosening exercises, various asana, and relaxation and Swiss ball
training includes15 minutes warm up, 30 minutes Swiss ball work outs and 15 minutes
cooling down. FFM and fat mass were tested by using Tanita body composition analyzer
before and after the training program for both experimental and control groups. Analysis of
covariance (ANCOVA) was applied to determine the significance difference between the
groups by using SPSS 16 version. Whenever the F ratio for adjusted post test mean was found
to be significant, the Scheffe’s test was applied as post hoc test to determine the paired mean
differences. For all analysis the level of confidence was fixed at 0.05. Discussion: The result
of the present study showed that the fat free mass and fat mass was significantly changed
after twelve weeks of Swiss ball exercises and Yogasana practices when compared with the
control group. Due to training the selected body composition such as fat free mass is
increased in both training group where as fat mass is reduced after the training program. Than
the Yogasana practice group. The present study result was supported by following authors
Telles et al., (Jan 2010), Pal et al., (June 2011). Chen and Tseng (2008).In Swiss ball training
muscles are worked more when compared with yoga practices. In yoga is a slow and steady
process, it will take more time than Swiss ball training in body composition. Both training is
advisable for reducing fat content in the body Conclusion: (1) There was a significant
difference among Swiss ball exercises and yogic practices on fat mass than the control group
after twelve weeks of yogasana practice and Swiss ball training. (2) There was a significant
difference among swissball exercises and yogic practices on fat free mass than the control
group after twelve weeks of yogasana practice and swissball training. (3) There was no
significant difference between swissball exercises and yogic practices group on body
composition after the twelve weeks of training period
Byoung-Do Seo et al.71 examined the effect of a Swiss ball exercise program for elderly
females on physical fitness and balance ability in order to offer basic data for the
development of an exercise program to improve the quality of life and promote the health of
elderly females. [Subjects] Sixty-five elderly women aged over 78 participated in this study.
[Methods] The subjects were divided into two groups: an exercise group and a control group.
The exercise group (n=38) performed a Swiss ball exercise program which consisted of 12
types of exercises required for balance and performance of functions twice a week for 12
weeks. Physical fitness (Sit-to-Stand, Arm Curl, Sit-and-Reach, Back Scratch) and balance
ability (One-Legged Standing time, Timed Up & Go) were evaluated. [Results] There was a
significant increase in the physical fitness and balance ability of the exercise group.
[Conclusion] The Swiss ball exercise program had a positive effect on physical fitness and
balance ability of elderly women. We consider that the ball which is easy, safe and interesting
to use will encourage the elderly’s active participation in exercise.
Parvadia72 reported the purpose of the present study was to find out the effect of selected
Swiss ball abs exercise on body fat percentage of overweight people. The sample of 30
overweight male between the ages 20-30 years were selected from the general population of
Bapunagar area Ahmedabad Gujarat, India. And the selected subjects were divided into two
groups i.e. 15 as Swiss ball Exercise group (Experimental) and 15 as Control group. In the
present study purposive -random sampling technique was used to select the sample. For
measuring body fat percentage the body Composition Analyzer and WHO's BMI norms table
were used. The BMI was calculated easily from the following formula BMI= (Weight in kg
/Square of height in meters). After assessment of pre-test of both groups then after
experimental treatment Swiss ball abs exercise programme was conducted for 15 weeks.
After the completion of 15 weeks Swiss ball abs exercise training, the post test (measure body
fat percentage) was conducted to know the significance difference between both group (Swiss
ball abs exercise group and control group). The ’t’ test was applied to analyses the data.
Statistically significant effect of Swiss ball abs exercise group was great improvement found
on body fat percentage of experimental group II as compared to control Group I at. 05 level
of significance.

REVIEW OF RELATED LITERATURE OF PILATES EXERCISE


REHABILITATION PROGRAM
Aladro Gonzalvo73 reported objective: The purpose of this systematic review was to
determine how Pilates exercises have impacted body composition (BC) on selected
populations. Methods: A comprehensive literature search was performed using the keywords
‘Pilates, body composition, systematic review, literature review, overweight, obesity, healthy
weight, underweight’ and their combination. Results: Seven studies met the inclusion criteria
and after further quality analyses it was determined that there is currently poor empirical
quantitative evidence indicating a positive effect of Pilates exercises on BC. Several
methodological flaws were observed in the studies analyzed, including few full-text published
studies looking into the effects of Pilates exercises on BC, a lack of true experimental
research designs, limited standardization in measurement techniques, insufficient or no
control of the nutritional status, and inconsistent instructor qualifications. Conclusion: Well-
designed research is needed to determine how Pilates exercises impact BC on selected
populations.
Segal N A74 has pointed out that the effects of Pilates training on flexibility and body
composition: an observational study. Objective: To assess claims regarding the effects of
Pilates training on flexibility, body composition, and health status. Design: An observational
prospective study. Setting: A community athletic club. Participants: A sample of 47 adults
(45 women, 2 men) who presented for Pilates training. Interventions: Not applicable. Main
outcome measures: Fingertip-to-floor distance, truncal lean body mass by bioelectric
impedance, health status by questionnaire and visual analogue scale were assessed at
baseline, 2, 4, and 6 months (±1wk). Results: Thirty-two of 47 enrolled subjects met the
protocol requirements of missing no more than 1 weekly 1-hour session Pilates mat class
during each 2-month period. Investigators were blinded to measurements from previous time
points. Median (Inter quartile range [IQR]) fingertip-to-floor distance improved from baseline
by 3.4cm (1.3–5.7cm), 3.3cm (0.3– 7.8cm), and 4.3cm (1.5–7.6cm) at 2, 4, and 6 months,
respectively (paired nonparametric analysis, all P<.01). There were no statistically significant
changes in truncal lean body mass, height, weight, or other body composition parameters.
Self-assessment of health also did not change in a statistically significant manner from its
baseline median (IQR) value of 77mm (69–85mm). Conclusions: Pilates training may result
in improved flexibility. However, its effects on body composition, health status, and posture
are more limited and may be difficult to establish. Further study might involve larger sample
sizes, comparison with an appropriate control group, and assessment of motor unit
recruitment as well as strength of truncal stabilizers.
Russell Jago75 considered the research background: There is a need to find ways to increase
the physical activity levels and improve the body composition and blood pressure of girls.
Methods: Thirty 11-year-old girls were recruited from two after school programs in Houston
Texas in Spring 2005. Participants from one program (16) were randomly assigned to
intervention, the other (14) served as controls. BMI, BMI percentile, waist circumference and
blood pressure were assessed before and after the intervention. Pilates classes were provided
free of charge for an hour per day at the intervention site, 5 days a week, for 4 weeks. Four
participants wore heart rate monitors during every session and completed enjoyment and
perceived exertion questionnaires. Repeated measures analysis of variance with time (within)
and group (between) as factors was performed. Results: Mean attendance was 75%, mean
heart rate 104 bpm, mean perceived exertion 5.9 (1–10 scale) and enjoyment 4.4 (1–5 scale).
There was a significant (P = 0.039) time by group interaction for BMI percentile. Graphs
indicated that this difference was influenced by large reductions in the BMI percentile of
healthy girls. Conclusions: Girls enjoyed Pilates, and participation for 4 weeks lowered BMI
percentile. Pilates holds promise as a means of reducing obesity.
Lu Yan and Zhang Shanbin76 studied the effect to understand the Pilates physical exercises
physiological indicators of female college students (body shape, fitness, physical
function),and further explore the Pilates exercises on physical fitness of female university
students and its mechanism, this study randomly selected school 60 female college
students(age 19.12±1.08),one of the control group(n=30) for normal learning and living, and
the experimental group(n=30) were carried out in a 16-week Pilates physical exercises.
Laboratory tests show: after 16 weeks of the Pilates physical exercises, one of the vital
capacity to increase from 2430.7±429 to 3071.68±408,waist skin fold thickness decreased
from 14.55±2.75 to 12.28±3.01,sit and reach from 11.61±5.47 to 17.94±5.18.Female college
students can be drawn through Pilates physical exercises before and after cardio-pulmonary
function, body fat, flexibility and other indicators of significant difference.
According to O. Cakmakci77 reported the objective of this study was to explore the effects of
8-weeks modern Pilates’ mat and ball exercise program on body mass, waist circumference
and waist to hip ratio on sedentary obese women total of 58 health sedentary obese women
volunteered to participate in this study. They were divided randomly into 1 of 2 groups:
Pilates training group (PTG; N=34) and control group (CG; N=27). A Pilates training
program was applied to the subjects one hour per day four days per week during 8 weeks. The
subjects in the control group did not participate in the training and participated only in the pre
and post test measurements. BMI, waist circumference, Waist-hip ratio, 4-site skin fold
thickness (Biceps, Triceps, Sup scapula and Iliac), fat percentage, resting metabolic rate,
Lean body mass and flexibility were assessed before and after the Pilates training program.
The SPSS statistical program (version 16.0) was used for data analysis. Analyses of
covariance (ANCOVAs) were run on each of the dependent variables. For all analyses, the
criterion for significance was set at an alpha level of p<0.05. 8 weeks of Pilates training
program has been found to be effective on weight, Body mass index, Lean body mass, waist-
hip ratio, biceps, triceps, fat percentage, basal metabolic rate, and flexibility in PTG (p<0.05).
The control group showed no significant differences in the same measures post-intervention.
As a result there was a positive effect of Modern Pilates mat and ball exercises of reducing
obesity, body composition parameters and flexibility at sedentary obese women.
Ruiz- Montero 78 reported the background: The purpose of this study was to examine the
differences in anthropometric measurements using an aerobic and Pilates exercise program
which lasted 24 weeks. Method: This was a clinical intervention study of 303 women over the
age of 60 living in Novi Sad, Serbia. Changes in body mass index and skin fold thickness
were estimated through height, weight, and anthropometric measurements. The program
comprised Pilate’s exercises for upper- and lower-body strength, agility, and aerobic capacity.
Results: Fat mass (FM) improved significantly (pre-test, 32.89%, 8.65; post-test, 28.25%,
6.58; P<0.01). Bone diameters and muscle perimeters showed no significant changes pre- and
post-test (P>0.05), but there was a higher correlation between FM (%) and waist–hip ratio
(rho, 0.80; P<0.01). Conclusion: A mixed program of aerobics and Pilates controls and
improves baseline muscle mass and decreases FM values, without causing deterioration
during practice and follow-up exercises.
M Fourie79 has pointed out the research background: With ageing, the ability to mobilize fat
is reduced and this, coupled with gradual decrease in lean body mass (LBM) from lessened
exercise, allows for an increased body fat percentage (%BF). Exercising is considered a key
to maintaining an appropriate body mass (BM), as it improves fat oxidation, while
maintaining LBM. Although the effects of endurance and/or resistance training on fat mass
(FM) and LBM in the elderly have well been established, limited data are forthcoming
regarding the effects of Pilates as a training modality on these variables in the elderly.
Objective: The present study was therefore conducted to determine the effects of a mat Pilates
programme on body fat in elderly women. Methods: Fifty sedentary, apparently healthy
females aged 60 years and older were randomly assigned a control (CG, n = 25) or an
intervention (IG, n = 25) group. The IG took part in an eight-week progressive mat Pilates
exercise programme, three times weekly while the CG were instructed to maintain their
normal daily activities throughout the eight-week experimental period. All subjects
underwent pre- and post-test in which FM and LBM were assessed. Results: Eight weeks of
mat Pilates demonstrated a significant (p < 0.05) decrease in % BF (p = 0.016) and FM (p =
0.038), with a significant increase in LBM (p = 0.006), while not showing any significant
changes (p > 0.05) in BM (p = 0.979) and BMI (p = 0.992). The CG, however, did not
produce any significant (p > 0.05) changes in any of the tested anthropometric variables (BM:
p = 0.266; BMI: p = 0.123; % BF: p = 0.516; FM: p = 0.937 and LBM: (p = 0.522) after
completion of the eight-week Pilates programme. Conclusion: An eight-week mat Pilates
exercise programme may contradict or even reverse some of the most serious consequences
of ageing associated with an increased fat mass and reduced lean body mass in elderly
females.
Anne and Marcello80 examined the changes in body composition (fat mass and lean body
mass) related to an aerobic-Pilates program in elderly Serbian women.1 The authors
concluded that “a combined program of aerobic and Pilates, carried out under the supervision
of an instructor, at least twice a week, produces health benefits in functionally independent
women over the age of 60”. This conclusion is overly optimistic and not supported by the
evidence provided. The authors used an uncontrolled study design so that, by definition, the
observed changes in anthropometric endpoints can at best be interpreted as preliminary
evidence of the effectiveness of the exercise program. Further, the evidence provided for the
effectiveness of the exercise program is very weak. The authors attributed the changes in
outcomes to the exercise program, but ignored the potential effect of the imposed study diet,
health education, and other factors that may have independently affected the anthropometric
outcomes. The endpoints chosen by the authors are surrogate outcomes, not patient relevant
outcomes, so it is incorrect to refer to health benefits. With the exception of the waist-to-thigh
ratio, imprecise thus not statistically significant changes were observed in muscle perimeters
(ten outcomes), skin fold thickness (seven outcomes), and bone measurements (four
outcomes). However, the authors inaccurately report “As for skin fold thickness, various
results were obtained (P<0.05)”, and fail to address the problem of multiple testing in their
discussion. In contrast, the observed change in fat mass may be of interest, but the clinical
relevance of the magnitude of this finding is not discussed, nor is it put in context with the
imposed study diet or other confounding factors. In conclusion, the authors seem to base their
conclusions on an incorrect interpretation of their data, providing yet another example for the
necessity of multidisciplinary collaborations, where at least health care specialists,
biostatisticians, and methodologists team up to design, conduct, and report clinically
meaningful research.
REVIEW OF RELATED LITERATURE OF GYMNASTICS FLOOR
REHABILITATION PROGRAM
Brendon Gurd, Panagiota Klentrou 81 have evaluated the purpose of this study was to
evaluate the effect of intense training on physical growth and sexual maturation in young
male gymnasts. Physical development, pubertal development, testosterone levels, energy
expenditure, and relative body fat were examined in 21 circumpubertal male gymnasts (13.3
± 0.3 yr) and 24 age-matched controls (13.5 ± 0.3 yr). Subjects completed a self-assessment
of genital and pubic hair development with the use of the Tanner scale. All subjects were
measured for height, weight, and salivary testosterone levels (T). The Physical Activity
Questionnaire for Adolescents was used to estimate weekly energy expenditure in metabolic
equivalents. Percent body fat (%BF) was assessed by using bioelectrical impedance analysis.
Developmental stages and T, as well as height and weight, were not different between groups.
Energy expenditure was significantly higher (P ≤ 0.05) and %BF was lower (P ≤ 0.05) in
athletes than in controls, but lean body mass was not significantly different between groups.
Energy expenditure was negatively correlated (P ≤ 0.05) with %BF but not related to T.
Developmental stages were strongly (P ≤ 0.05) related to T but not to energy expenditure or
%BF. It is concluded that, although there is a higher energy expenditure accompanying
intense training in young male athletes, their body composition is not necessarily affected,
and there is no determined effect on their physical and pubertal development.
Erlandson, Marta Christine 82 reported the dramatic rise in health care and economic costs as
well as increases in morbidity and mortality related to lifestyle behaviours and non-
communicable diseases have resulted in an increasing emphasis on research and intervention
initiatives aimed at primary prevention. As there is growing evidence that the antecedents of
adult diseases such as obesity and osteoporosis have roots in early childhood, physical
activity interventions in early childhood (4 to 6 years of age), which has been identified as a
critical period, may influence the development of fat and bone mass at this young age and
have a potential impact on adolescent and young adult health status and thus improve
population health. The intent of this study was to investigate the effects of structured physical
activity, specifically early involvement in gymnastics, on early childhood body composition
development. Sixty three (25 male and 38 female) 4 to 6 year old children participating in
gymnastics programs were compared to 95 control (49 male and 46 female) children.
Anthropometric measurements included height, weight, BMI, waist circumference, and skin
fold thickness. Dual energy x-ray absorptiometry (DXA) was used to measure whole body
bone density and fat mass. Physical activity, physical inactivity, dietary intake, and birth
weight of the participants as well as parental heights and weights were also obtained. No
significant differences were found, at any age, between the groups in height, weight, BMI,
waist circumference, skin fold thickness, physical activity, physical inactivity, dietary intakes,
and birth weight or in parental heights and weights (p>0.05). Additionally, there were no
significant differences in fat and bone parameters once the confounders of age and size were
controlled (p>0.05). This investigation found that young children entering a gymnastics
program did not differ in either bone mass or fat mass compared to controls. This was
surprising as differences in these parameters have been found in adolescent gymnasts. Thus
my results indicate that the potential effects of gymnastics training may have not yet
manifested themselves. To answer this question longitudinal measures are required to
ascertain whether the body composition differences observed in adolescent gymnasts are due
to prolonged exposure to gymnastics involvement.

Emma M. Laing et al.83 made a comparison the objective: to examine changes in bone and
body composition of adolescent female artistic gymnasts (GYM; n = 7), level 5+, compared
with non gymnast controls (CON; n = 10) over 3 years. Study design: Areal bone mineral
density (aBMD; g/cm2), bone mineral content (BMC; g) and bone area (cm2), of the total
body (TB), total proximal femur (TPF), trochanter (Tr), femoral neck, lumbar spine (LS), and
distal radius were measured using dual-energy X-ray absorptiometry. Fat-free soft tissue mass
(FFST; g), fat mass (g), and percent body fat (%FAT) were also assessed. Results: No initial
differences in height or weight between GYM and CON were observed, and both groups
demonstrated parallel increases in these parameters over time (P <.05; h2 ≥0.15). At baseline,
GYM possessed significantly lower %FAT and higher aBMD at all sites (except TB; P <.05;
h2 ≥0.15). Over 3 years, GYM increased more than CON (P <.05; η 2 ≥0.15) in TB, Tr, and
TPF aBMD, TB and LS BMC, and FFST. Conclusion: Female adolescents participating in
competitive artistic gymnastics training over 3 years have enhanced rates of aBMD, BMC
and FFST accrual. (Journal Pediatrics 2002; 141: 211-6)
I.C. Elendu and O.A. Umeakuka 84 examined a cross-sectional survey design was used to
explore the weight-loss practices among gymnasts in Rivers State, Nigeria. Data were
collected from eighteen gymnasts using 11-item structured questionnaire. The generated data
were analyzed using percentage and chi-square statistics. Results showed that majority of the
gymnasts decreased their consumption of calories (77.78%), increased their expenditure of
calories through exercise (88.89%), restrict food (94.44%), over-exercise (83.33%) and
engage in voluntary fluid reduction or dehydration (83.33%) to lose weight. Among the
findings was that the gymnasts' gender, age and years of sporting experience had significant
influence on increase expenditure of calories through exercise, food restriction, use of drugs,
use of nutritional supplements and use of steam baths or saunas for weight-loss. Among the
recommendations are that nutritionist/dieticians should be employed and integrated into the
gymnastics team to provide and guide the gymnasts on how to effectively use healthy and
supervised nutrition to lose weight. The gymnasts should be educated on the health and
performance effects of engaging in harmful weight-loss practices through seminars.
Stakeholders should be sensitized on the weight-loss practices. This will enable them to
discourage any gymnast planning to adopt unhealthy weight loss measures.
Alfredo Irurtia Amigoa et al. 85 reported introduction and aims: The aim of the present study
was to characterize the evolution of height and weight (from 7 to 25 years old) and
somatotype and body composition (from 12 to 18 years old) in elite male gymnasts. Method:
For each of the variables, a mixed-longitudinal design was used to analyze: a) its evolution
with age and b) its differences with respect to a reference population. Somatotype was
analyzed with the Heath-Carter method, fat free mass with the Slaughter formula and muscle
mass with the Portman formula. Results: Male gymnasts were significantly shorter and lighter
than the reference population. The best gymnasts were even more so with respect to their
fellow gymnasts, except for specialists in vault and floor where the lower limbs are especially
important. The peak height velocity occurred at the age of 14, at the same age as in the
reference population. The somatotype was ecto-mesomorphic in 90% of the gymnasts. Fat
mass percentage was significantly lower than in the reference population. Somatotype, fat
free mass and muscle mass showed no significant increases with age. Conclusions: Gymnasts
showed a growth pattern considered as normal in the variables analyzed in the present study.
The main differences between the gymnasts and the reference group were observed from the
beginning of the follow-up. These findings suggest the effects of a selection process, both
before and during the training process, before the elite level is reached.
Haitao Chen et al86 investigated for top level female gymnasts; effective body fat reduction
is a long-term process, often resulting in various issues; how to keep the physical fitness at an
optimal level? How to control the amount of training to improve skill and performance? This
report presents a case study of a successful weight loss program used by the Chinese National
Gymnastics Team when preparing for the 2008 Olympic Games. Results: Over 28 days the
participant lost 840 grams of body weight, of this 356 grams were fat. The participant
achieved the optimal balance between fitness and body weight. She developed a desirable
mental condition for competition and managed to achieve a respectable result at the 2008
Olympic Games. Conclusion: In conclusion, the results of this study suggest that body weight
control is an important aspect for elite gymnasts in preparation for competition. The
regulation of food intake and energy balance contributes to the optimal body weight for
performance. Further studies are needed for body weight management of the top level
gymnasts.
Sule Kirba and Sedef Kurt87 have pointed out that the study aims at identifying the impact of
three to six month-programs for step aerobics and aerobic gymnastics on sedentary women's
anthropometric measurements. This study covered a total of 44 volunteer women who have
never done exercise before and with the average age of 38.25±6.43 years, the average height
of 162.04±5.53 cm and the average weight of 69.88±14.61 kg. The 1st group is composed of
20 participants while the 2nd group consists of 24 participants. Those who did exercise for
three months make up the 1st Group whereas the 2nd Group is composed of those who did
exercise for six months. At the heart rate of 50-60 %, the 1st group was made to do exercise
for 60 minutes and 3 days a week during a 12-week span as the 2nd group did exercise for 60
minutes and 3 days a week during a 24-week span. The 1-hour exercise program includes 5-
minute warming up, 15-minute aerobics, 20-minute step aerobics, 15-minute floor gymnastics
and 5-minute cooling down. The intensity of the exercise was determined by identifying the
target heart rate in accordance with the heart rate reserve method (Karvonen). The subjects
were measured in weight, height and body mass % on a Tanita scale. The statistical analysis
of the data acquired was conducted by the SPSS package program. The groups were
compared on a paired simple t-test. P<0.05 was deemed significant. It was concluded from
the study on comparison of the groups that the age and VFR 2 scores were statistically
significant at the level of p<0.01 and p<0.05 respectively. There was no statistically
significant difference between other variables in spite of some numerical differences
(p>0.05). As a conclusion, the age difference between two groups indicates that people tend
to exercise less as they grow older and that results from the decline in regular exercise in the
society as people age. The numerical values indicate that doing exercise has a positive impact
on women's body mass % whereas no statistically significant result and instability in values
result from subjects' age range, constantly sitting down at work, metabolic or hormonal
reasons, malnutrition and social habits.
REVIEW OF RELATED LITERATURE OF AQUATICS EXERCISE
REHABILITATION PROGRAM
Joanna Kantyka et al.88 examined purpose: the aim of the present investigations was to
determine the effects of aqua aerobics on body weight and composition, lipid profile, and
selected blood count parameters in middle-aged sedentary females. Methods : Twenty-one
women were randomly assigned to an experimental group (age 56.20} 2.57 years, height
162.80} 4.76 cm, weight 74.03} 3.84 kg) that participated in aqua aerobics classes three times
a week for three months and a control group (mean age 56.4} 3.28 years, height 165.00}3.91
cm, weight 70.01} 11.36 kg) not involved in any kind of targeted exercise. The aqua aerobics
classes were tailored to suit the age and abilities of the participants, with workout intensity
controlled and maintained at approximately 128–137 bpm. Results: Significant differences
between the experimental and control groups were found for body weight, total body water,
fat-free mass, and skeletal muscle mass. A significant increase in post-intervention
hemoglobin and erythrocyte counts was observed in the experimental group. Conclusions:
Future studies should determine the intensity of physical activity with the most beneficial
effect on blood variables in middle-aged and older individuals.
Bo-Ae Lee and Deuk-Ja Oh89 investigation the purpose of this study was to investigate the
effects of aquatic exercise on body composition, physical fitness, and vascular compliance of
obese elementary school students. For the purpose of this study, 20 obese elementary students
were selected as subjects. The subjects were then divided into two groups: the swimming
group (n= 10) and the control group (n= 10). The subjects were asked to exercise for 60
minutes a day, 3 times a week for 12 weeks with an exercise intensity of 50–70% HRmax.
The following results were achieved: first, in terms of body composition, both body fat
percentage and fat-free mass showed significant differences within the swimming group.
There were also significant differences again in the post test of difference between the two
groups. Second, in terms of changes in physical fitness, there were, again, no significant
changes in muscular strength between the two groups. However, muscular endurance,
flexibility, and cardiopulmonary endurance showed significant differences in the swimming
group’s test for difference within groups. Significant differences in both groups for the
posttest of differences between groups were also seen. Third, in terms of vascular
compliance, there was a significant increase in the right leg for the swimming groups’ test of
difference within groups, as well as in the post test of difference between groups.
Gappmaier E. et al90 reported the aim: It has been suggested, that water exercise is less
effective than weight-bearing exercise on land for body fat reduction. Methods: To test these
hypothesis 38 middle-aged obese women (25-47% body fat) participated in a 13 week
exercise-diet program to compare the effects of aerobic exercise in water versus walking on
land on indices of fat reduction and weight loss changes. Subjects were randomly assigned to
1 of 3 exercise groups: 1) walking on land (WL), 2) swimming (SW) at 27 degrees C water
temperature and 3) walking in 29 degrees C water (WW) at the shallow end of a declining
pool with the water at navel height. Subjects in the SW group alternated breast-, side-, and
backstroke swimming without face immersion. Exercise parameters were kept constant for all
three groups. Subjects participated in supervised exercise sessions for 40 min, 4 times a week
at 70% of age-predicted maximum heart rate. Subjects were tested before and after the 13-
week experimental period. Results: Significant reductions in body weight, (5.9 kg), percent
body fat, (3.7%), and skin fold and girth measurements, occurred in all groups. There were no
significant differences between groups. Conclusions: The results of this study indicate that
there are no differences in the effect of aerobic activities in the water versus weight-bearing
aerobic exercise on land on body composition components as long as similar intensity,
duration and frequency are used.
Juan Carlos Colado et al.91 determined the effects of a supervised strength training program
on body composition and physical capacity of older women using three different devices:
weight machines, elastic bands, and aquatic devices that increase drag forces (ADIDF). Four
groups were formed: control group, weight machine group (WMG), elastic band group (EBG)
and a group that used ADIDF (ADIDFG). Body composition and physical capacity were
assessed before and after the intervention period. The ADIDFG showed improvements in fat
mass (FM), fat-free mass of the left arm (FFM-LA) and right arm (FFM-RA), knee push-up
test (KPT), squat test (ST) and crunch test (CT) (p <0.05). Individuals in the EBG and WMG
also improved their FM, fat free mass (FFM), FFM-LA, FFM-RA, KPU, ST and CT. ADIDF
training improves body composition and physical capacity of postmenopausal women as does
performing land-based training programs.
Eveline J. M. Wouters et al.92 has pointed out that the aim and method : To examine in obese
people the potential effectiveness of a six-week, two times weekly aqua jogging program on
body composition, fitness, health-related quality of life, and exercise beliefs. Fifteen
otherwise healthy obese persons participated in a pilot study. Results: Total fat mass and
waist circumference decreased 1.4 kg and 3.1 cm, respectively. The distance in the Six-
Minute Walk Test increased 41 meters. Three scales of the Impact of Weight on Quality of
Life-Lite questionnaire improved: physical function, self-esteem, and public distress.
Increased perceived exercise benefits and decreased embarrassment were observed.
Conclusions: Aqua jogging was associated with reduced body fat and waist circumference
and improved aerobic fitness and quality of life. These findings suggest the usefulness of
conducting a randomized controlled trial with long-term outcome assessments. Ryszard
Jasinski et al. 93 experiment that the Nordic walking and water aerobics are very popular
forms of physical activity in the elderly population. The aim of the study was to evaluate the
influence of regular health training on the venous blood flow in lower extremities and body
composition in women over 50 years old. Twenty-four women of mean age 57.9 (±3.43)
years, randomly divided into three groups (Nordic walking, water aerobics, and nontraining),
participated in the study. The training lasted 8 weeks, with one-hour sessions twice a week.
Dietary habits were not changed. Before and after training vein refilling time and thefunction
of the venous pump of the lower extremities were measured by photo
plethysmography. Body composition was determined by bioelectrical impedance. Eight
weeks of Nordic walking training improved the venous blood flow in lower extremities and
normalized body composition in the direction of reducing chronic venous disorder risk
factors. The average values of the refilling time variable (p = 0.04, p = 0.02, respectively)
decreased in both the right and the left leg. After training a statistically significant increase in
the venous pump function index was found only in the right leg (p = 0.04). A significant
increase in fat-free mass, body cell mass and total body water was observed (p = 0.01),
whereas body mass, the body mass index, and body fat decreased (p < 0.03). With regard to
water aerobic training, no similar changes in the functions of the venous system or body
composition were observed.
Elizabeth F. Nagle 94 determined the effects of the non-weight-bearing method of aquatic
exercise as a modality for weight loss have not been established. The purpose of this study
was to examine the effects of a combined aquatic-exercise and walking program compared
with walking alone on body weight and selected variables in obese women undergoing a 16-
week standard behavioural treatment program. Methods: Forty-four obese (body-mass index
34.9 ± 3.8 kg/m2) sedentary women age 40.3 ± 6.8 years were randomly assigned to one of
two groups: aquatic and walking exercise (AE) or walking only (W). In addition, both groups
were required to complete three sessions of home-based walking per week and were
instructed to reduce energy intake to facilitate weight loss. Results: In the AE group, total
body weight, cardio respiratory fitness, flexibility, strength, and health-related quality of life
significantly improved over time similarly to the W group. Slightly greater non significant
losses in body weight, improvements in flexibility, greater attendance rates, and significantly
greater enjoyment scores also occurred in the AE group. Conclusion: These observations
suggest that aquatic exercise in combination with walking can serve as an alternative to
walking exercise alone for overweight women during periods of weight loss, and this can
improve functional health status.
Maria Fragala-Pinkham95 made a comparison children with disabilities have lower physical
activity levels and participate less in community-based sport and exercise programs than do
children without disabilities. This in part is due to environmental barriers and lack of
appropriate resources in these programs. Adaptive programs encouraging increased physical
activity for children with disabilities are needed, and as these programs are developed,
theyshould be critically evaluated. Purpose: The purposes of this article are to describe a pilot
aquatic exercise program for children with disabilities, to evaluate the program, and to
determine areas of strength and areas needing modifications. Methods: A summative program
evaluation design was used to assess this twice per week aquatic exercise program lasting 14
weeks. Sixteen children, ages 6-12 years, with developmental disabilities participated in the
program. Children swam laps, participated in relay races and water basketball games, and
performed arm and leg strengthening exercises using aquatic noodles, foam barbells, and
water for resistance. Swimming skills, program evaluation questionnaires, physical activity
questionnaires, and interviews of pool site directors were used to determine program
outcomes. Results: Findings suggest that children made improvements in their swimming
skills, parents were satisfied with the program, and children increased their physical activity
levels during the program and maintained the increased physical activity levels six months
after the program ended. The program continued in some form after the 14-week intervention
ended. Conclusions: The program was successful in achieving its objectives and
recommendations for application of this program are provided.

REVIEW OF RELATED LITERATURE OF SCHOOL BASED HEALTH AND


FITNESS RELATED PROGRAM
Kristine96 reported the Alliance for a Healthier Generation’s Healthy Schools Program
(HSP) is a national evidence-based obesity-prevention initiative aimed at providing the
schools in greatest need with onsite training and technical assistance (TTA) and consultation
with national experts (HSP national advisors) to create sustainable healthy change in schools’
nutrition and physical activity environments. The objective of this study was to evaluate the
impact of HSP on the prevalence of overweight and obesity in Bareilly schools, from HSP’s
inception in 2006 through 2012. Methods: We used state-wide body mass index (BMI) data
collected annually from 5th-, 7th-, and 9th-grade students to determine whether enrolling in
the HSP’s onsite intervention reduced the prevalence of overweight and obesity in
intervention schools (n = 281) versus propensity-score matched control schools (n = 709) and
whether increasing exposure to the program (TTA and contact with HSP national advisors)
was associated with reductions in the prevalence of overweight and obesity. Results:
Analyses showed no difference between HSP schools and control schools in overweight or
obesity prevalence. However, program exposure varied widely among participating schools,
and each additional contact with TTA or HSP national advisors was associated with a 0.3
Percentage decline in overweight and obesity prevalence (P<.05).Conclusion HSP appears to
be an important means of supporting schools in reducing obesity. Although participation in
HSP alone was not sufficient to improve weight status in Bareilly schools, there was a clear
dose–response relationship to the program. HSP serves as an effective model for addressing
childhood obesity among engaged schools Miller97 examined the obesity and poor physical
fitness is major health care concerns for children. These conditions are associated with future
insulin resistance, type 2 diabetes mellitus, lipid abnormalities, and hypertension. The
combination of increased caloric intake and decreased physical activity causes obesity in
children. Addressing caloric intake and food selection alone may not resolve the underlying
issues of insulin resistance and poor cardiac fitness. In adults, the leading predictor of
cardiovascular and all-cause mortality is the level of physical fitness and not weight status.
Because most adults do not perform moderate exercise 30 minutes per day on most days of
the week as recommended, establishing healthy habits in children is important to reach this
physical fitness goal. Various behavioural interventions in childhood have had mixed results.
In a recent study, a school-based exercise program for adolescent girls resulted in an increase
in physical activity and prevented the decline in cardiovascular fitness normally seen in this
age group. Carrel and colleagues evaluated the effectiveness of a school-based fitness
program on body composition, cardiovascular fitnesslevel, and insulin sensitivity in
overweight children. Children from one middle school whose body mass indexes (BMIs)
were above the 95th percentile for their ages were invited toparticipate in the study. Before
the intervention and at the end of the nine-month school year, data on height, weight, fasting
blood glucose and insulin levels, body composition, andcardiovascular fitness were obtained
by physical examination. After the baseline data werecollected, the children were assigned
randomly to the intervention or standard gym classes.
Fifty-three students agreed to participate in the study, with 27 assigned to the intervention
group. Students in the intervention group received a small nutrition education component that
included information on healthy eating habits. The intervention group was divided into small
classes (12 to 14 students) to allow for increased instructor attention, more opportunity for
motivation, and less time standing in line. The curriculum was personalized to better match
the students' skills. During the class, lifestyle-focused activities such as walking, cycling, and
snowshoeing were emphasized. In the standard gym class, the children participated in more
traditional sports. The main outcome measures were cardiovascular fitness, fasting insulin
and glucose levels, and body composition. At baseline, the groups were similar with regard to
age, BMI, percentage of body fat, lean body mass, and maximum oxygen consumption. The
intervention group had a significantly greater loss of body fat (–4.1 percent) compared with
the standard gym class group. They also had a significantly greater increase in cardiovascular
fitness compared with the standard gym class. Fasting insulin levels decreased by 5.1 µIU per
mL (35.4 pmol per L) in the intervention group, compared with an increase of 3.0 µIU per
mL (20.8 pmol per L) in the control group. No one in the intervention group dropped out,
whereas three students dropped out of the control group for reasons unrelated to the study.
The authors conclude that a fitness-oriented, school-based intervention can have a positive
effect on body composition, cardiovascular fitness, and fasting insulin levels in overweight
children. The authors add that, as part of the public health approach to improving the health
of overweight children, partnering with school districts is an important component of any
intervention. Aaron L. Carrel98 conducted research that the obesity and poor physical fitness
constitute a health problem affecting an increasing number of children. Causes include a
pervasive “toxic” environment that facilitates increased caloric intake and reduced physical
activity. An effective strategy for prevention and treatment of childhood obesity likely
includes a collaborative effort in the school setting. Objective: To determine whether a
school-based fitness program can improve body composition, cardiovascular fitness level,
and insulin sensitivity in overweight children. Design: Fifty overweight middle school
children with a body mass index (BMI) above the 95th percentile for age were randomized to
life style focused, fitness-oriented gym classes (treatment group) or standard gym classes
(control group) for 9 months. Children underwent evaluation of fasting insulin and glucose
levels, body composition by means of dual energy absorptiometry, and maximum oxygen
consumption (V O2max) treadmill testing at baseline (before the school year) and at end of
the school year. Settings: Rural middle school and an academic children’s hospital. Main
Outcome Measures: Baseline test results for cardiovascular fitness, body composition, and
fasting insulin and glucose levels. Results : At baseline, there were no differences between
groups before intervention (values for age, 12 ± 0.5 years [all results, mean ± SD]; BMI
[calculated as weight in kilograms divided by the square of height in meters], 31.0 3.7;
percentage of body fat, 36.5% 4.6%; lean body mass, 41.4 8.6 kg; and V O2max, 31.5 ± 5.1
mL/kg per minute). Compared with the control group, the treatment group demonstrated a
significantly greater loss of body fat (loss, −4.1% ± 3.4% vs −1.9% ± 2.3%; P = .04), greater
increase in cardiovascular fitness (V O2max, 2.7 ± 2.6 vs 0.4 ± 3.3 mL/kg per minute;
P<.001), and greater improvement in fasting insulin level (insulin level, −5.1 ± 5.2 vs 3.0 ±
14.3 µIU/mL [−35.4 ± 36.1 vs 20.8 ± 99.3 pmol/L]; P = .02). Conclusions: Children enrolled
in fitness-oriented gym classes showed greater loss of body fat, increase in cardiovascular
fitness, and improvement in fasting insulin levels than control subjects. The modification to
the school physical education curriculum demonstrates that small but consistent changes in
the amount of physical activity has beneficial effects on body composition, fitness, and
insulin levels in children. Partnering with school districts should be a part of a public health
approach to improving the health of overweight children.
Lavelle99 examined childhood obesity predisposes to adult obesity and increases the risk of
many diseases. Schools provide a vehicle to deliver public health interventions to all children.
Methods: Medline and Embase were used to undertake a systematic review of published
studies of school-based interventions aimed at reducing the body mass index (BMI) of
children ≤ 18 years. Preferred reporting items for systematic reviews and meta-analyses
guidelines were followed, and eligible studies subjected to a random effects meta-analysis.
Results: Between 1991 and 2010, 43 published studies provided 60 measurements of effect.
The pooled effect was a 0.17 (95% CI: 0.08, 0.26, P< 0.001) reduction in BMI. Heterogeneity
was high (I2= 93.4%) but there was no significant small study bias (Egger's test, P= 0.422)
nor significant variation by length of follow-up. The intervention comprised physical activity
only in 11 (26%) studies, education only in three (7%), and combinations of these and
improved nutrition in the remaining 29 (67%). On stratified analysis, physical activity used in
isolation (−0.13, 95% CI: −0.22, −0.04, P= 0.001) or combined with improved nutrition
(−0.17, 95% CI: −0.29, −0.06, P< 0.001) was associated with significant improvements
inBMI. Interventions targeted at overweight/obese children reduced their BMI by 0.35 (95%
CI: 0.12, 0.58, P= 0.003). Those delivered to all children reduced it by 0.16 (95% CI: 0.06,
0.25, P= 0.002). Conclusions: There is growing evidence that school -based interventions that
contain a physical activity component may be effective in helping to reduce BMI in children.
William B. Strong100 has reviewed the effects of physical activity on health and behaviour
outcomes and develops evidence-based recommendations for physical activity in youth.
Study design: A systematic literature review identified 850 articles; additional papers were
identified by the expert panelists. Articles in the identified outcome areas were reviewed,
evaluated and summarized by an expert panelist. The strength of the evidence, conclusions,
key issues, and gaps in the evidence were abstracted in a standardized format and presented
and discussed by panelists and organizational representatives. Results: Most studies used
supervised programs of moderate to vigorous physical activity of 30 to 45 minutes duration 3
to 5 days per week. The panel believed that a greater amount of physical activity would be
necessary to achieve similar beneficial effects on health and behavioural outcomes in
ordinary daily circumstances (typically intermittent and unsupervised activity). Conclusion:
School-age youth should participate daily in 60 minutes or more of moderate to vigorous
physical activity that is developmentally appropriate, enjoyable, and involves a variety of
activities.
CHAPTER 4

RESULT AND DISCUSSION

This section detail down the results and the discussion of the observation and investigation on
120 females subjects who had BMI values exceeding 27. Keeping in view the aims of the
present study, that is the exploration of the effects of four weeks of different types of weight
reduction program (Interferential treatment, aerobic exercise program and administered to the
three different groups of females on the weight reduction program given to the Interferential
treatment group, Interferential treatment coupled with hot water application), the fourth group
named as the control group on the other hand did not receive any treatment or weight
reduction intervention. The morphological measurements like height, weight, skinfold
thickness at biceps, triceps, subscapular, suprailliac and abdomen sites were taken on all the
subjects belonging to the four groups on three occasions i.e.
before the starting of the program and after two weeks and again after four weeks of the
completion of the different programs. To meet the objectives set for the study, suitable
statistical treatment has been given to the data. The various morphological measurements
were compared by applying paired ‘t’ test before the program, after two weeks program and
after four weeks of the different weight reduction programs data.
Analysis of Variance test (ANOVA) was also applied to the different groups and wherever
ANOVA indicated statistically significant differences between the groups, Scheffe post hoc
test was applied to identify the groups which statistically differed from each other. The aim of
the present study stands to identify the best results of the effects of four weeks weight
reduction program among different groups. The results of this study have been formed into
tables and also illustrated with the help of figures and diagrams wherever necessary.
COMPARISON OF DIFFERENT GROUPS OF FEMALES REGARDING THEIR
DIETARY, ANTHROPOMETRIC STATUS AMONG DIFFERENT GROUPS OF
FEMALES
As dietary intake plays an important role in the weight regulation of the subjects, the present
section deals with the comparison of dietary status of the subjects belonging to the different
groups of the study. The results pertaining to the dietary status have been presented and
discussed under the following subheadings.
Comparison of Average Age (years), Height (cms) and Body Mass Index (Kg/m2) among
different group of females
1. Comparison of average Daily Dietary Intake of Nutrients among Different Groups
2. Comparison of Anthropometric Profiles of Females belonging to different group.
3. Comparison of Predicted minimum weight values program of Females belonging to
different group.
Comparison of Average Age (years), Height (cms) and Body Mass Index (Kg/m2) different
group of females Figure 4.1 & Table 4.1 compare the mean values of age of the subjects of
different groups. It was found that maximum mean age of subjects was demonstrated by the
Interferential treatment group (33.17 yrs), followed by the Control group (32.77 yrs),
Interferential treatment + hot water application (30.00 yrs) and aerobic group (27.90 yrs) in
the decreasing order. On an average females belonging to the IFT group are observed to be
0.4, 2.77 and 5.47 years older than the females belonging to the control, IFT + hot water
application group and aerobic groups in that order. Statistical comparison of mean ages
among the different groups as done by the application of ANOVA (Table 4.2) revealed that
the mean age differences among the different groups were statistically significant and the
Scheffe post hoc test (Table 4.3) revealed that the subjects belonging to the Interferential
treatment + hot water application group and the control group were observed to be
significantly older than the aerobic group. Tzankoff and Norris (1978) reported that increase
in age leads to decrease in physical activity that in turns may be responsible for decrease in
resting metabolism and gain of fatty tissue in the body.
Figure 4.2 & Table 4.1 depicts the mean values of body height along with its statistical
correlates among the different four groups of females. The females belonging to the aerobic
group were observed to be taller (158.05±4.05cm) than the females belonging to the
Interferential treatment + hot water application (157.48±3.48 cm) group, followed by the
Interferential treatment group (155.60±5.20cm ) and the control group (154.74±4.87 cm)
females were observed to be shortest in body stature as compared to all the other groups.
Application of ANOVA indicates absence of statistically significant differences in the mean
heights among these four groups as evidenced by F value (Table 4.2). The height of the
subjects is inversely proportional to the BMI of the subject, which is important indicating
predisposition factor for overweight, diabetes and coronary artery disease.
Figure 4.3 compares the body mass index of different groups of females. Maximum mean
value of body mass index was demonstrated by the females belonging to the Control group
(31.51 ± 4.39 kg/m²) followed by Interferential therapy (30.08 ± 2.66 kg/m²), Interferential
therapy (29.16 ± 2.74 kg/m²) group and the minimum mean BMI value was found in the
aerobic group of females (27.64 ± 1.67 kg/m²). BMI value is considered a useful indicator of
weight possessed by an individual relative to his height and normal range of BMI for adults
has been reported to range between 18 to 25. Females belonging to the present study groups
on an average surpass the upper limit of the rangeand therefore can be considered overweight
that is they possess greater body weights in relation to their respective heights. Application of
Analysis of variance test on the data revealed the presence of statistically significant mean
differences in BMI among the
groups. Further exploration through Scheffe post Hoc test revealed the presence ofsignificant
mean differences in BMI between the Control group and Interferential group, Control group
and Aerobic group, Interferential group & the Aerobic groups (Table 4.4).
(b) Comparison of Average Daily Dietary Intake of Nutrients Among Different
Group of females.

Figure 4.4 & Table 4.5 represent the comparison of the mean values of daily dietary intake of
energy among the four different groups of females. The maximum mean value of total daily
dietary intake of energy was observed in the Interferential treatment + hot water application
group (2648.97 kcal.± 284.10 kcal) followed by the IFT group (2570.36 kcal ±421.38kcal.),
the control group (2550.18 kcal±421.38kcal) and the aerobic group (2331.46 kcal±
400.13kcal.). The females belonging to the Interferential treatment + hot water application
group on an average ingest around 78 to 317 Calories more than their counterparts belonging
to the other three groups. The results of application of ANOVA test (Table 4.6) however
revealed the existence of non significant differences in total daily dietary energy intake
among the four groups of females. On an average the subjects of present study consume
although comparable daily energy intake but the average intake is observed to be greater than
the ICMR recommendations which is 2225 Kcal per day.
Studies have shown that the prevalence of obesity, the mean BMI, or the body weight
decreases as the amount of exercise increases (Williamson, 1996; French et al, 1994;
Williamson et al, 1993).
Mean values of daily energy expenditure among the various groups of females are presented
in Table 4.5. It is observed that aerobic group on an average expends more calories/day than
the other groups followed by the control; the IFT + hot water application and the IFT group
(Figure 4.5). After analysis of variance the results were found to indicate statistically
significant differences among the groups. The differences were found to be significant in
statistical terms between the Control group and the IFT group, the Control group and the
Aerobic group, and between the Interferential group and the Aerobic groups.
It can be further observed that total daily energy intake by the different groups of females on
an average exceeds the total daily energy expenditure. In case of the aerobic group the
difference between the total daily energy intake and the daily energy expenditure is only 51
Cal/day while in the other three groups the difference is large and ranges between 481 to 598
Cal/day. This observation and the body of evidence point from various studies point to a
rather week coupling between energy intake and physical activity induced energy expenditure
(King et al. 1997., King 1998 and Blundell King 1998). The failure of some investigators to
report a linkage between energy intake and physical activity may be the fact that the energy
intake might not had been tracked in their studies for sufficiently long period of time after
increasing the physical activity. Edholm et al (1995) put forth his view that although there is
no relationship between energy expenditure and energy intake on the same day but there may
be a positive relationship between energy expenditure on one day and energy intake two days
later. Excessive ingestion of daily
energy over the daily energy expenditure suggest a positive state of balance leading to further
gain in body weight.
BMR is the minimum caloric requirement needed to sustain life in a resting individual. It can
be looked at as being the amount of energy (measured in calories)\ expended by the body to
remain in bed asleep all day. Figure 4.6 shows the calculated mean values of basal metabolic
rate of different group of females. Maximum BMR value was observed in the Control group
followed by the IFT + hot water group, IFT and aerobic exercise group. After application of
ANOVA, the differences were found to be non significant among the different group of
females.
A detailed dietary analysis in terms of major and minor nutrients consumed by the subjects
belonging to various groups has been made before the start of the exercise program. Mean
values of the daily dietary carbohydrates taken by the females belonging to the different
groups have been presented in Table 4.8 and illustrated with the help of histograms (Figure
4.7). IFT + Hot water application group of females exhibit maximum intake of total
carbohydrates (403.86 gms) in their daily diet followed by the control (393 gms), IFT group
(391.93 gms) and the aerobic group (366.82 gms) in the decreasing order (Figure 4.7).
ANOVA test indicates the existence of non significant difference among the various groups
(Table 4.9).
Carbohydrates are the main source of energy for a person's diet. They provide energy to cells
in the body, particularly the brain. Carbohydrates are one of the macronutrients that are
needed in large quantities. According to the Institute of Medicine (2005), people should
consume between 45-65% of their total caloric intake from carbohydrates. There are a variety
of different dietary components that fall into the category of carbohydrates including both
complex and refined carbohydrates.
Mean daily dietary intake of added sugar in the daily diet of the different groups of females
have been compared in figure 4.8 & Table 4.8. Interferential treatment + hot water
application group has been observed to consume maximum amount of added sugar in their
daily diet followed by the Interferential treatment group, the Control group and least in the
aerobic group respectively. After Analysis of variance, F value was found to indicate
existence of non significant differences in the comparison of daily added sugar intake in the
daily diet. All the four groups of females do not differ significantly from each other in their
daily dietary intake of added sugar.
Complex carbohydrates are carbohydrates that are made up of strings of simple sugars in a
chain. The action of digestive enzymes is much slower on this kind of carbohydrates as they
need to be broken down into simple carbohydrates for absorption in the body. This slow
digestion provides for a slow and steady energy supply to meet the requirements of the
individual cells without getting stored up as glycogen or fat. Average daily dietary intake of
complex carbohydrates in daily diet by females of various groups along with related
statistical constants are presented in Figure 4.9 & Table 4.8. Among the various groups,
females belonging to the Interferential treatment + hot water application group consume
maximum quantity of complex carbohydrate in their daily diet (341.76gms ± 46.36gms),
followed by the Interferential treatment group (339.09gms ± 42.38gms), the Control group
(338.09gms ± 66.43gms) and minimum in the aerobic group (321.60gms ±50.41gms)
respectively. After Analysis of variance, F value was found to indicate non significant
differences in the daily dietary intake of complex carbohydrates among the groups.
Fat is a necessary ingredient in the diet. Mean values of daily dietary intake of total fat in the
various groups are presented in Figure 4.10 & Table 4.10. Among the different groups,
females belonging to the Interferential treatment with hot water application demonstrates
maximum amount of total daily dietary fat (77.73 gm/day) ingestion in their daily diet
followed by the Interferential treatment group (74.02 gm/day), Control group (69.86 gm/day)
and the aerobic group (59.97 gm/day). On an average, the subjects of present study consume
more dietary intake of fats as compared with the Indian Council of Medical Research
recommendations (2005) which is 20gm/day. ANOVA application reveals statistically non
significant differences in the daily dietary fat ingestion among the different groups of females
(Table 4.11).
Saturated fats are a source of fuel for the body. Just like essential nutrients, the body requires
saturated fat. Cell membranes are made up of both unsaturated and saturated fatty acids,
which mean the body needs a variety of fat sources. Without saturated fat, body loses to
stiffness, and is unable to function properly. Saturated fats also contribute to immune health
and brain health. The results of the present study revealed maximum mean daily consumption
of saturated fats in the Interferential treatment with hot water application
(23.17gms/day±6.68gms/day) group and minimum in the aerobic group (18.46gms/day ±
5.86gms/day). After application of ANOVA, F value was found to be non significant among
different females groups.
Regarding polyunsaturated fatty acids (PUFA), controlled feeding and cohort studies of
eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) intakes have demonstrated
physiological benefits on blood pressure, heart rate, triglycerides, and likely inflammation,
endothelial function, and cardiac diastolic function, and consistent evidence for a reduced risk
of fatal CHD and sudden cardiac death at consumption of ~250 mg/day of EPA plus DHA
(Burr et al., 1989; Gissi-Hf, 2008; Mozaffarian and Rimm, 2006; Yokoyama et al., 2007).
DHA also plays a major role in development of the brain and retina during foetal
development and the first two years of life (Cetin and Koletzko, 2008; Decsi and Koletzko,
2005; Helland et al., 2008). Keeping in view the importance of unsaturated fats in the daily
diet, a comparison of dietary ingestion of unsaturated fats and fats from plant sources in the
daily diet of the four groups of the study has also been done.

Monounsaturated fats and fatty acids help keep the heart healthy by reducing total
cholesterol, triglycerides and "bad" LDL cholesterol, while increasing levels of HDL
cholesterol in the blood. Fats are needed for normal growth and development in children, and
they help the brain and central nervous systems to be healthy. They also produce hormone-
like substances that regulate blood pressure, blood clotting and the immune system. Average
daily consumption of mono fat is found to be maximum in the Interferential treatment with
hot water application group (21.41gms/day±6.79gms/day) followed by the Interferential
treatment group (20.13gms/day±5.50gms/day), Control group (19.05gms/day±7.38gms/day)
and minimum in the aerobic group (16.38gms/day±6.79gms/day). Statistically speaking the
differences were found to be non significant among different females groups (Table 4.11).
The escalating incidence of Syndrome X (central obesity, dislipidemia and glucose
intolerance) has helped bring a more “moderate” approach to the Dietary Guidelines for
Americans regarding fat’s percentage of total kcal (Gifford, 2002). Additionally, an increased
recognition of the types of dietary fat has broadened scientific understanding beyond simply
saturated and unsaturated fatty acids. Further, researchers have referred to the potency of
various dietary lipids as pharmaceutical in nature (DeCaterina et al., 1996; Fauconnot and
Buist, 2001; Watkins et al., 2001). For example, monounsaturated fattyacids, as common to
the Mediterranean diet, may reduce cardiovascular risks beyond any effects on plasma lipids,
such as via blood pressure normalized glucose tolerance (Perez- Jimenez et al., 2002;
Rasmussen et al., 1995; Thomsen et al., 1995). Highly unsaturated omega-3 fatty acids found
in cold water fish reduce inflammation (Browning, 2003; Calder, 1997, 2001; Endres et al.,
1989; Endres, 1996; Kremer et al., 1987), mediate psychiatric function (Logan, 2003; Su et
al., 2003), alter neuro-endocrine activity (Delarue et al., 2003), and decrease cardiac mortality
(Richter, 2003). A Dietary fat and sports
nutrition less common fatty acid found in dairy and beef, conjugated linoleic acid (CLA), has
the ability to dramatically alter body composition in animal models (Belury and Koster,
2004). This type of understanding is leading to changes in both dietary recommendations
(American Heart Association, 2002) and a wide variety of dietary lipid supplements.
Figure 4.13 & Table 4.12 presents the comparison of average daily dietary intake of plant fats
among different groups of females. Maximum daily dietary intake of plant fats was found in
the Interferential with hot water application group (59.43gms/day±20.82gms/day), followed
by the Interferential group (56.59gms/day±20.82gms/day), Control Group
(52.38gms/day±20.00gms/day) and minimum in the aerobic group
(44.54gms/day±16.95gms/day). ANOVA indicates existence of significant mean differences
among the different groups of females (Table 4.13).
Figure 4.14 & Table 4.12 shows the comparison of mean daily dietary consumption of poly
fats among different groups of females. Maximum consumption of poly fats was observed in
the Interferential treatment with hot water application group (29.02 gm/day±11.19) followed
by the Interferential treatment group (28.51 gm/day±12.06), the Control group (26.02
gm/day±10.37) and minimum in the aerobic group (21.52 gm/day±7.48). After application of
ANOVA, the differences were found to be non significant among the different groups of
females. Female groups don’t differ from each other in their daily dietary intake of poly fats.
Fat is a necessary ingredient in the diet and it is of value to the body in a number of ways.
Animal fats such as butter and ghee contain vitamin A. Figure 4.15 & Table 4.12 present the
mean daily dietary intake of animal fats in different groups of females.
Maximum consumption of daily dietary Animal fat ingestion is shown by the Interferential
treatment with hot water application group (18.22gms/day±7.10gms/day), followed by the
Interferential treatment group (17.47gms/day±4.74gms/day), Control group
(17.37gms/day±5.54gms/day) and least in the aerobic group (16.16 gms/day±4.92)
respectively. The differences in the daily animal fat intake of the subjects among the different
groups were not observed to be statistically significant (Table 4.13).

Protein constitutes an important component of the diet and must be provided daily in
adequate quantities to run the metabolism process smoothly. Maximum value of protein
intake is observed in the control group (90.07gm/day ±11.63gm/day) followed by the
Interferential treatment group (88.61gm/day±9.80gm/day), Interferential treatment+hot water
application group (88.50gm/day ±7.31gm/day) and the aerobic group (81.20gm/day ±
11.08gm/day) in that order. The results of ANOVA (Table 4.15) revealed existence of
statistically significant mean differences among the different groups of females. The Scheffe
post hoc test (Table 4.16) revealed that significant differences exist between the control group
and aerobic groups, Interferential treatment group and the aerobic groups and between the
interferential treatment with hot water application group and the aerobic group. The World
Health Organization and many national health agencies have
independently conducted studies, which (even though they differ slightly), all conclude that
ideally the daily protein requirement should be between 10% to 15% of our daily caloric
intake. The daily protein intake of females has been observed to be higher in the present study
groups than the ICMR recommended dietary allowance for Indians (50 g/d).
The importance of proteins for athletes has continued to be debated over years. Clark et al
(1988) reported that the primary fuel for muscular contraction was derived from muscle
protein and further suggested that large quantities of meat should be taken to replenish the
supply. The studies conducted by Lemon (1987) and Lamont et al (1990) failed to confirm
the above mentioned results and gave the concepts that changes in protein metabolism during
exercise are non existing or minimal at best. However, studies using modern technology have
concluded that proteins are a much more important fuel source during exercise than was
previously thought (Hickson et al, 1985; Nair et al, 1987; Tarnopolsky et al, 1988 and Lemon
et al, 1992). The value of proteins to those persons who exercise is due to the fact that
exercise cause significant muscle damage (Evans, 1991), increase in amino acid oxidation
(Dohm, 1985; Lemon, 1987; Lamont, 1990 and Phillips et al, 1993) and increase in
gluconeogenesis (Dohm, 1985 and Nair et al, 1987). From the evidence available from these
studies, it is understandable that the proteins should be available in the exercising individual’s
body in appropriate amounts to deal with the wear and tear caused by the work out. In the
light of the reasons cited above, an increase in the protein intake ofthe females seems quite
justified.
The major sources of animal protein include lean meats, fish, poultry, eggs and dairy
products. When animal protein is digested, it produces acidic by-products which are high in
phosphorous. Figure 4.17 compares the mean daily dietary intake of animal protein among
different group of females.
CHAPTER 5

RESULT AND CONCLUSION


In this chapter the results obtained have been discussed in the light o f relevant research
according to the hypothesis laid down. Considering the objectives, the chapter has been
divided into two parts.
Parti of results (Analysis Of Variance)
This part considered the results regarding effect of gender and level of obesity on subjects’
quality of life, subjective well-being, sexual satisfaction and health.
Part II of results (Correlation Analysis)
This part considered the results regarding relationship among subjects’ Quality of Life,
Subjective Well-Being, Sexual Satisfaction and Health (physical, emotional and
psychological distress).
Part 1 (Analysis Of Variance)
Quality of Life
1. Quality of Life and Gender
2. Quality of Life and Level of Obesity
3. Quality of Life and Interaction Effect Subjective Well-Being
4. Subjective Well-Being and Gender
5. Subjective Well-Being and Level of Obesity
6. Subjective Well-Being and Interaction Effect Sexual Satisfaction Sexual Satisfaction
and Gender.
7. Sexual Satisfaction and Level of Obesity
8. Sexual Satisfaction and Interaction Effect Health Physical Distress
9. Physical Distress and Gender
10. Physical Distress and Level of Obesity
11. Physical Distress and Interaction Effect
12. Emotional and psychological Distress
13. Emotional and Psychological Distress and Gender
14. Emotional and Psychological Distress and Level of Obesity
15. Emotional and Psychological Distress and Interaction Effect
Interest m the psychological aspects of patients with different diseases continues to grow.
Recent years have witnessed a dramatic rise m the prevalence of obesity worldwide,
stimulating interest in the psychological and behavioural consequences of this phenomenon.
The body of research on die obese individuals has grown to a point that a review of this
literature is warranted. Numerous studies have demonstrated that obese persons experience
significant impairments m their psychological function as a result of their obesity. As the
relationship between body weight and psychological factors is wellknown but inconclusive
(Conca et al., 2008; Fnedman & Brownell, 1995; Fnedman, Reichmann, Constanzo, &
Musante, 2002; Wadden & Stunkard, 1993), more research is needed to clarify whether
psychological aspects differ in obese persons.
Further, a number of factors influence the relationships among obesity and psychosocial
functioning. These factors include race, gender and degree of overweight. To date research is
less advanced in understanding the relationship between obesity and their accompanied
psychological aspects. Therefore the present study is an effort to investigate the following
aspects of obese persons in relation to their gender and level of obesity-
Quality of Life
Subjective Well-Being
Sexual Satisfaction
Health
Physical Distress
Emotional and psychological Distress

Quality of Life
Though prevalence of obesity has been documented among large sections of general
population, little is known about the grave impact obesity has on the quality of life. Quality
of life is now emerging as a central construct within a number of fields, such as those related
to the social sciences, medicine and economics. Prior to 1970s, quality of life didn’t receive
much attention m the medical or public health literature.
However, the scenario has changed since then. Obesity is often reported to be associated with
impaired quality of life (QOL). The term "quality of life" has different meanings to different
people although it has been widely used for long. For some clinicians and research workers,
quality of life is related to almost anything beyond information about death and death rates.
For some others quality of life is an umbrella concept that broadly embraces various aspects
of a person's life, including physical and mental health, psychological well-being, social and
financial wellbeing, family relationships, friendships, work and work environment, leisure
activities and the like.
Descriptive information for all experimental groups appears in figure 4.1. This figure unveils
the mean score of each experimental group on measure of Quality of Life (PGIQOLS). It is
evident from this figure that among all experimental group A1B1 and A2B1 group scored
higher whereas group A1B3 obtained lesser score on their measure of quality of life. Higher
score indicates better quality of life. It reveals that male and female with low level of obesity
are less impaired in their quality of life as compared to male and female with severe obesity.
Table 4.2 illustrates the inferential information (ANOVA) and computed F values for gender
and level of obesity on measure of quality of life among obesity patients. Table shows the
main effect for both variables as well as the effect of the interaction between them. The
computed F values were found to be significant for both variables (Gender and Level of
obesity) which reveals that obese male and female are significantly different on their level of
quality of life. Simultaneously level of obesity is significant on subjects’ level of quality of
life.
As interaction between gender and level of obesity was found to be insignificant, obese male
and female are not significantly different on their quality of life according to their level of
obesity.
The result table 4.3 and figure 4.2 shows mean scores on measure of Quality of life
(PGIQOLS) for the gender groups which indicated that male and female differ less on their
measure of quality of life. Although mean scores for gender indicate that both male and
female are slightly different m their score on measure of Quality of life but as computed F
value which is found to be significant, it does not support the above conclusion. It was also
noted however, that despite statistical significance, the magnitude of differences was rather
small between male and female. The result revealed that biological factor i.e. gender is
prominent for ones’ level of their quality
of life they spent.
Regarding male and female difference in their quality of life, previous research has indicated
that the relationship of obesity to quality of life is more pronounced among male than female.
Contradictory to the conclusions of this research, in a study by Kolotkin RL, Crosby RD,
Kosloski KD, Williams GR (2001), it was revealed that within obese samples, women are
sometimes, although not always, found to have lower QOL. At lower levels of BM1, more
pronounced gender differences have been reported as compared to relatively higher levels of
BM1 (Kolotkin RL, Crosby RD, Kosloski KD, Williams GR. (2000). Similarly White,
Mamey A., Patrick M. Kolotkin, and T. Karlbyme (2004) reported that women showed the
most impaired QOL than males. In same regard Bentley TG, et. al (2011) assessed in their
study
that health-related quality of life (HRQoL) varies by body mass index (BMI) among gender
and racial subgroups using nine HRQoL measures. And revealed that health related quality of
life (HRQoL) scores were significantly lower for obese than normal-weight among women (P
= 0.04) but not men (P = 0.11).
Overall, the current findings support and extend the existing research on gender and QOL, As
the present study reported significant difference for gender on quality of life the alternative
hypothesis regarding gender effect on quality of life has been proven, hence accepted here.
Above result table and respective figure shows that obese patients are different intheir level of
quality of life according to their degree of obesity. Analysis of Variance (ANOVA) further
indicated that as the levels of obesity increases, patients reported more impaired QOL.
Along the same lines, in study of Stacy A. Ogbeide, Christopher A. Neumann, C. Diane
Rudebock and Brian E. Sandoval (2010) reported that compared to participants in the
“normal” weight range, participants classified as “overweight/ obese” reported lower levels of
life satisfaction. Correspondingly Fontaine KR, Cheskin LJ, Barofsky I. (1996) and Kolotkin
RL, Crosby RD (2002) studied relationship between QOL and level of BMI and have
reported that QOL impairment worsens with increasing obesity. In addition, the obtained
result of the present investigation was found to be consistent with the study of Kolotkin RL,
Meter K and Williams GR (2001), who demonstrated that obese persons experience
significant impairments in quality of life as a result of their obesity, with greater impairments
associated with greater degrees of obesity. Similarly Kushner RF and Foster GD (2000) also
focused on the impact of obesity on quality of life and reported that obesity confers negative
consequences on both the physical and
psychosocial aspects of quality of life, especially among the severely obese.
imilarly Mamey A. White, Patrick M. O’Neil, Ronette L. Kolotkin, and T. Karl Byrne (2004)
investigated obesity-related quality of life (QOL) and shown that at increasing levels of
overweight, mdividuals report more impaired QOL. Compared to previous studies, the
observed relationships between BMI and QOL were somewhat attenuated.
Finkelstem (2000) also examined the relationship between BMI and health-related quality of
life among of a sample of primary care patients. The study found that health-related quality of
life scores varied between BMI levels (e.g., normal, overweight, and obese).
On the basis o f present result as well as consistent aforementioned studies it can be
concluded that, increase in level o f obesity is associated with worsened quality o f life. Thus
the result confirmed the alternative hypothesis in the same regard.
Quality of Life and Interaction Effect
Hypothesis c)
There will be no significant effect o f interaction between gender
and level o f obesity on Quality o f life among obesity patients.

The above result table presents the computed F values for interaction of gender with level of
obesity on measure of quality of life among obesity population. It is evident from the results
that quality of life of male and female does not significantly differ with regard to their level
of obesity. To conclude, quality of life score is not significantly associated with interaction
between gender and level of obesity.
Consistent with the present result the study of Bentley TG, et. al (2011) was found to be in
line with the present result. In his study they assessed how health-related quality of life
(HRQoL) vanes by body mass index (BMI) category among gender and racial subgroups
using nine HRQoL measures. Results revealed that HRQoL was significantly lower (P<
0.0001) with increasing BMI category. Obese individuals were 5.3 units lower on PCS (1-100
scale) and 0.05-0.11 lower on the HRQoL indexes (0-1 scale) than those with normal weight.
MCS scores were
significantly lower for obese than normal-weight among women (P = 0.04) but not men (P =
0.11). Overweight blacks had higher HRQoL than blacks in other BMI categories (P = 0.033).
They further concluded that six commonly used HRQoL indexes and two of three health
status summary measures indicated lower HRQoL with obesity and overweight than with
normal BMI, but the degree of decrement varied by index. The association appeared driven
primarily by physical health, although mental health also played a role among women.
As hypothesized, the obtained result unveils that QOL would not differ in different groups
based on their degree o f obesity across gender. Therefore, the considered null hypothesis was
proven true and hence accepted here.
Subjective Well-Beins
Person with obesity face stigmatization and discrimination in many areas of their lives, and it
has been assumed that their psychological well-being will be compromised as a result.
Subjective well-being seems to be somehow related to Obesity as a disease.
Subjective well-being has been studied in a large number of disciplines over many centuries
and has been defined m ethical, theological, political, economic and psychological terms
(Diener, 1984; Veenhoven, 1984). In psychology, subjective well-being is defined as people’s
assessment of their lives. People evaluate their lives in several ways. First, people make their
judgement about their lives- whether their lives are fillfilling, satisfying and meaningful.
People also evaluate specific aspect of their lives such as their marriages, health, and work
and leisure time. In addition, people react to events with affect (moods and emotion); positive
or pleasant affect, when things are going well and negative or unpleasant affect, when things
are going badly. Thus subjective well-being is an umbrella term that refers to these different
forms of evaluations’ of one’s life and colloquially called happiness as well as psychological
well-being.
Studies of clinical samples typically report poorer psychological well-being in obese. A
number of important moderators and mediators of the association between obesity and well-
being have emerged. This study sorts out the effect of gender and level of obesity on
subjective well-being among obese.
Above result table 4.6 shows the mean score of each experimental group on measure of
Subjective well-being (SUBI). It is evident from this table that among allexperimental groups,
A1 Bland A2B1 groups obtained respectively higher scores as compared to other groups on
their measure of subjective well-being (SUBI), which revealed that male and female who
were categorised on low level of obesity as per BM1 possess good sense of well-being than
those who comes under moderate and severe level of obesity. Overall this finding leads
towards the conclusion that as the level of obesity increases among both male and female,
level of one’s subjective
well-being diminishes regardless of their gender.

Above result table 4.7 presents the F values for gender and level of obesity on
measure of Subjective well-being (SUBI) among obesity patients. The computed F values
were found to be significant for both i.e. gender and for level of obesity but for their
interaction it was found to be insignificant, which revealed that- • Obese male and female are
significantly different on their sense of subjective well-being.
1. There is a significant difference among all three groups of obesity patients in their
sense of subjective well-being.
2. Gender and level of obesity does not significantly interact with each other m order to
determine ones’ level of subjective well-being criteria.
LITERATURE CITED
Adeyemo, A., Luke, A. and Cooper, R. 2003. A genomewide scan for body
mass index among Nigerian families. Obes. Res., 11: 266-273.

Afridi, A.K. and Khan, A. 2004. Prevalence and etiology of obesity. Pak. J.

Nutr., 3 (1): 14-25.

Albu, J.B., Murphy, L., Frager, D.H., Johnson, J.A. and Pi-Sunyer, F.X. 1997.
Visceral fat and race-dependent health risks in obese non-diabetic
premenopausal women. Diabetes, 46: 456-462.

Allison, D., Heshka, S., Neale, M.C. and Heymsfield, S.B. 1994. Race effects
in the genetics of adolescents’ body mass index. Int. J. Obes. Relat.
Metab. Disord., 18: 363-368.

Allison, D.B. 1995. Methodological issues in obesity research: examples from

new directions in assessment and management. In: Obesity. (Eds.)

VanItallie TB, Simopoulos AP. Charles Press, Philadelphia: 129-132.

Allison, D.B. and Pi-Sunyer, F.X. 1995. Obesity teatment: Establishing goals,
improving outcomes and reviewing the research agenda. New York:
Plenum Press.

Allison, D.B., Faith, M.S. and Nathan, J.S. 1996. Risch’s lambda values for
human obesity. Int. J. Obes., 20: 990-999.

Allison, D.B., Kaprio, J. and Korkeila, M. 1996a. The heritability of body mass
index among adolescents aged 16 years and 17 years: A study of 4884
twins and 2509 singletons. Int. J. Obes. Relat. Metab. Disord., 23: 107-
115.
Allison, D.B., Kaprio, J. and Korkeila, M. 1996b. The heritability of body mass
index among an international sample of monozygotic twins reared apart.
Int. J. Obes. Relat. Metab. Disord., 20: 501-506.

Allison, D.B., Pietrobelli, A., Faith, M.S., Fontaine, K.R., Gropp, E. and
Fernández, J.R. 2003. Genetic influences on obesity. In: Eckel R (Ed).
Obesity: Mechanisms & Clinical Management. Elsevier: New York: 1-
74.

American Heart Association, 1998. Understanding Obesity in Youth. Report


No. 71- 0099. The American Heart Association, Public Information,
7272 Greenville Avenue, Dallas, TX 75231-4596, USA.

American Heart Association, 2002. Guidelines for weight management.


Programs forhealthy adults. American Heart Association, 7272
Greenville Avenue, Dallas, TX 75231-4596, USA.

American Institute for Cancer Research. 2008. The Environmental Roots of


Obesity. http://www.aicr.org/site/News2?page=NewsArticle&id=14229.

Andreyeva, T., Roland, S. and Jeanne, S.R. 2004. Moderate and severe obesity
have large differences in health care costs. Obes. Res., 12(12): 1936-
1943.

Angell, J.L. 1949. Constitution in female obesity. Am. J. Phy. Anthropol., 7:

733-771.

Baron, R.B. 2006. Nutrition. In. Current Medical Diagnosis and Treatment.
(Eds.). Tierney, Lawrence M, McPhee, et al., Mc GrawHill, USA: 1267-
1269.
Barsh, G.S., Farooqi, I.S. and O’Rahilly, S. 2000. Genetics of body-weight
regulation. Nature, 404: 644- 651.

Bell, C.G., Walley, A.J., and Froguel, P. 2005. The genetics of human obesity.

Nature, 6: 221-234.

Berkey, C.S., Rockett, H.R., Field, A.E., Gillman, M.W. and Colditz, G.A.
2004. Sugar-added beverages and adolescent weight change. Obes. Res.,
12: 778-788.

Berrington, D. and Gonzalez, A. 2010. Body-mass index and mortality among


1.46 million white adults. N. Engl. J. Med., 363(23): 2211-2219.

Bes-Rastrollo, M., Sanchez-Villegas, A., Gomez-Gracia, E., Martinez, J.A.,


Pajares, R.M. and Martinez-Gonzalez, M.A. 2006. Predictors of weight
gain in a Mediterranean cohort. Am. J. Clin. Nutr., 83(2): 362-370.

Bhadra, M., Mukhopadhyay, A. and Bose, K. 2001. Body mass index, regional
adiposity and central body fat distribution among Bengalee Hindu girls:
A comparative study of pre-menarcheal and menarcheal subjects. Acta.
Med. Auxol., 33: 39-45.

Bhargava, S.K. 2004. Relation of serial changes in childhood body-mass index


to impaired glucose tolerance in young adulthood. N. Engl. J. Med.,
350(9): 865-875.

Bhasin MK and Chahal SMS. 1996. Techniques in blood grouping. In: A


laboratory manual for human blood analysis. Kamlaraj Enterprises,
Delhi: 86-89.

Bhattacharyya, S., Ganaraja, B. and Bhat, M. 2010. Correlation between the


blood groups, BMI and pre-hypertension among medical students. J.
Chin. Clin. Med., 5(2): 78-82.
Bindah, E.V. and Othman, M.N. 2011. The relationship between alcohol
consumption, dietary habit and obesity: A review. Aus. J. Basic. Sci.,
5(11): 1766-1771.

Birch, L.L. and Davisson, K.K. 2001. Family environmental factors


influencing the developing behavioral controls of food intake and
childhood overweight. Pediatr. Clin. North. Am., 48(4): 893-907.

Bleich, S., Cutler, D.M., Murray, C.J. and Adams, A. 2007. Why is the
Developed World Obese? NBER Working Paper 12954Bogardus, C.,
Lillioja, S., Ravussin, E., Abbot, W., Zawadski, J., Young, A., Knowler,
W., Tacobwitz, R. and Moll, P. 1986. Familial dependence of the resting
metabolic rate. N. Engl. J. Med., 315: 96-100.

Borecki, I.B., Higgins, M. and Schreiner, P.J. 1998. Evidence for multiple
determinants of the body mass index: the National Heart, Lung, and
Blood Institute Family Heart Study. Obes. Res., 6: 107-114.

Bose, K. 1995. A comparative study of generalised obesity and anatomical


distribution of subcutaneous fat in adult White and Pakistani migrant
males in Peterborough. J. Roy. Soc. Hlth., 115: 90-95.

Bouchard, C. 1991. Current understanding of aetiology of obesity: genetic and

non-genetic factors. Am. J. Clin. Nutr., 53: 1561-1565.

Bouchard, C. 2001. The genetics of human obesity: recent progress. Bull. Mem.

Acad. R. Med. Belg., 156: 455-462.


Bouchard, C. and Tremblay, A. 1990. Genetic effects in human energy
expenditure components. Int. J. Obes., 14: 49-55.

Bouchard, C., Perusse, L., Leblanc, C., Tremblay, A. and Theriault, G. 1998.

Inheritance of the amount and distribution of human body fat. Int. J.

Obes., 12: 205- 215.

Bray, G. and Popkin, B. 1998. Dietary fat intake does affect obesity. Am. J.

Clin. Nutr., 68: 157-173.

Bray, G.A. 2004. Medical consequences of obesity. J. Clin. Endocrinol.

Metab., 89(6): 2583-2589.

Bray, G.A. 2010. Soft drink consumption and obesity: it is all about

fructose. Curr. Opin. Lipidol., 21(1): 51-57.


Bray, G.A. and Bouchard, C. 2004. Handbook of obesity: etiology and

pathophysiology. Basel Dekker: New York.

Bray, G.A. and Champagne, C.M. 2005. Beyond energy balance: there is more

to obesity than kilocalories. J. Am. Diet. Assoc., 105 (Suppl 1): S17-S23.

Bray, G.A., Paeratakul, S. and Popkin, B.M. 2004. Dietary fat and obesity: a
review of animal, clinical and epidemiological studies. Physiol. Behav.,
83(4): 549-555.

Breslow, R.A. and Smothers, B.A. 2005. Drinking patterns and body mass
index in never smokers. National Health Interview Survey, 1997-2001.
Am. J. Epidemiol., 161: 368-376.

Briefel, R.R. and Johnson, C.L. 2004. Secular trends in dietary intake in the
United States. Annu. Rev. Nutr., 24: 401-431.

Brook, C. 1977. Genetic aspects of obesity. Post. Grad. Med. J., 53: 93-99.

Brook, C.G., Huntley, R.M. and Slack, J. 1975. Influence of heredity and
environment in determination of skin fold thickness in children. Br.
Med. J., 2: 719-721.
Buijsse, B., Feskens, E.J. and Schulze, M.B. 2009. Fruit and vegetable intakes
and subsequent changes in body weight in European populations: results
from the project on Diet, Obesity, and Genes. Am. J. Clin. Nutr., 90:
202-209.

Bulik, C.M., Sullivan, P.F. and Kendler, K.S. 2003. Genetic and environmental
contributions to obesity and binge eating. Int. J. Eat. Disord., 33: 293-
298.

Burdette, H.L. and Whitaker, R.C. 2004. Neighborhood playgrounds, fast food
restaurants, and crime: relationships to overweight in low-income
preschool children. Prev. Med., 38: 57-63.
Cardon, L.R., Carmelli, D., Fabsitz, R.R. and Reed, T. 1994. Genetic and
environmental correlations between obesity and body fat distribution in
adult male twins. Hum. Biol., 66: 465-479.

CDC (Centers for Disease Control and Prevention). 2010. Overweight and
Obesity. http://www.cdc.gov/obesity/htm.

Census of India. 2001. Provisional Population Totals: Punjab Data Sheets;


http://www.punjancensus.gov.in/

Census of India. 2011. Provisional Population Totals: Punjab Data Sheets;


http://www.punjancensus.gov.in/

Chang, V.W. and Lauderdale, D.S. 2005. Income disparities in Body Mass
Index and Obesity in the United States, 1971-2002. Arch. Intern. Med.,
165 (18): 2122-2128.

Chomplay, P. and Singh, S.K. 2011. Indian Cuisine. In Theory of cookery.

Aman Publishers, New Delhi: 124-127.

Christakis, N.A. and Fowler, J.H. 2007. The spread of obesity in a large social
network over 32 years. N. Engl. J. Med., 357: 370-379.
Clement, K. and Ferre, P. 2003. Genetics and the pathophysiology of obesity.

Pediatr. Res., 53: 721-725.

Clement, K., Vaiesse, C. and Lahlou, N. 1998. A mutation in the human leptin
receptor gene causes obesity and pituitary dysfunction. Nature, 392:
398-401.

Coon, K.A., Goldberg, J., Rogers, B.L. and Tucker, K.L. 2001. Relationships
between use of television during meals and children’s food consumption
patterns. Pediatr., 107(1): 7.

Cummings, D.E. and Schwartz, M.W. 2003. Genetics and pathophysiology of


human obesity. Ann. Rev. Med., 54: 453-471.