Journal of the Formosan Medical Association (2012) 111, 153e159
Available online at www.sciencedirect.com
journal homepage: www.jfma-online.com
ORIGINAL ARTICLE
The influence of a behavior modification interventional program on body mass index in obese adolescents* Tahereh Toulabi a,*, Mohsen Khosh Niyat Nikoo b, Fariba Amini a, Hedayat Nazari c, Mahnaz Mardani d a
Department of Nursing, School of Nursing and Midwifery, Lorestan University of Medical Sciences, Khorram Abad, Iran Endocrinology and Metabolism Research Center, Tehran University of Medical Sciences, Tehran, Iran c Department of Psychiatry, School of Medicine, Lorestan University of Medical Sciences, Khorram Abad, Iran d Department of Nutrition, School of Medicine, Lorestan University of Medical Sciences, Khorram Abad, Iran b
Received 14 August 2010; received in revised form 1 February 2011; accepted 4 May 2011
KEYWORDS behavior modification; BMI; depression; exercise; modifying dietary habits
Background/Purpose: The prevalence of obesity and overweight among children and adolescents is increasing rapidly. The present research was performed to determine the influence of a ‘‘behavior modification’’ program on body mass index (BMI) in obese public high school students in Iran. Methods: In this study, 152 adolescence and their parents were selected from 12 high schools of Khorram Abad from 2004 to 2006, and they were randomly assigned to either the intervention or the control groups. The “behavior modification” interventional program consisted of nutritional education, modifying dietary habits, teaching exercise programs, teaching nutritional facts to the parents, and performing exercises 3 days a week. The height and weight as well as waist, hip, and wrist circumferences of the participants were measured before and after implementing the interventional program. BMI and waist to hip ratio (WHR) were calculated. The adolescents and parents completed a nutrition knowledge questionnaire. Adolescents also completed the Beck’s Depression Questionnaire. Results: Adolescent’s mean weight, BMI, and waist and hip circumferences decreased significantly after implementing the interventional program, in the intervention group (p 0.001). In addition, the students’ and parents’ nutrition knowledge increased in the intervention group after implementing the interventional program (p < 0.046). The symptoms of depression decreased and the frequency of students without symptoms of depression increased in the case group, but it did not reveal a statistically significant difference between case and control groups.
*
The abstract was presented as an oral presentation at the 3rd Balkan Congress on Obesity in October 2008. * Corresponding author. Department of Nursing, School of Nursing and Midwifery, Lorestan University of Medical Sciences, Khorram Abad, Iran. E-mail address:
[email protected] (T. Toulabi).
0929-6646/$ - see front matter Copyright ª 2012, Elsevier Taiwan LLC & Formosan Medical Association. All rights reserved. doi:10.1016/j.jfma.2011.05.007
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T. Toulabi et al. Conclusion: The ‘‘behavior modification’’ interventional program is effective in reducing BMI in obese students, and therefore, school principals and planners can play an important role in controlling obesity by implementing this program via the students, their parents, and the school staff. Copyright ª 2012, Elsevier Taiwan LLC & Formosan Medical Association. All rights reserved.
Introduction The prevalence of obesity and overweight among children and adolescents is increasing rapidly and is nowadays regarded as a general health problem.1 According to the reports released by the National Center of Health Statistics (2002), an estimated 16% of Americans aged 6 years to 19 years are obese. These numbers represent an alarming 45% increase from just a decade ago.2 Of the high school students of Khorram Abad, Iran (2005), 9.7% were overweight and obese, and there was a significant relationship between these variables and father’s job, parent’s level of education, having breakfast, and monthly income.3 Although obesity imposes great costs on the medical and economical sectors, the plans and strategies devised for the prevention and the treatment of obesity are imperfect. In addition to genetic factors (parental obesity),4 gender, and ethnicity, other factors such as inappropriate dietary habits (especially the drive for consuming palatable, i.e., sweet and high fat, foods), the increased amount of time spent on sedentary screen-based activities, and the decreased amount of physical activity are factors associated with obesity in children and adolescents.5 Studies have shown that obesity is related to the daily distribution of the intake energy, or with less breakfast intake and much more lunch and dinner.5,6 Regular breakfast consumption has been identified as an important protective factor against poor nutritional status and obesity.7e9 A study that examined lifestyle behaviors in 1966 high school students in Khorram Abad showed that the consumption of fried and high-fat foods, sweet and salty food, snacks, and sugary beverages was higher in the obese group.5 The complications of obesity and chronic illnesses have been well documented in recent years, and overeating is responsible for 280,000 deaths each year.6 In addition, individuals who are obese during childhood and adolescence will also be obese during adulthood.10 Obesity during childhood and adolescence increases the incidence of the metabolic, chronic, and cardiovascular diseases and the risk of premature death during adulthood.11e13 The results of a study that included 5881 adults showed that for each incremental increase in body mass index (BMI), the risk of heart failure increases 5% in men and 7% in women.14 Low self-confidence, depression, and anxiety,15,16 dropping out of school in lower grades, poverty, and low income level are among the other consequences of obesity.17 The results of a quasi-experimental study (2009) in Iran showed that although there were no significant differences between the mean BMI of the students’ in the two groups after intervention, implementing this program to control risk factors for obesity regarding dietary pattern and physical activity was successful. Therefore, it is recommended to
investigate the effectiveness of such interventions over time in further studies.18 Thus, the importance and the urgency of interventional measures for changing the lifestyle behaviors associated with obesity is evident in numerous studies.19,20 In Harris et al’s study (1980), in a long-term weight control program, it was found that few participants lost large amounts of weight.21 One of the reported programs for behavior modification involved eight female participants who performed exercises in 20-minute sessions, 3 sessions a week, for 4e5 weeks, and thereafter performed exercises every other week for 3 months, and experienced 17.2 kg weight loss on average.22 Other studies suggest that the combination of behavior therapy and drug therapy is more effective than either therapy alone.23e25 Sixty-four of the researches undertaken from 1985 to May 2008 were Randomized Controlled Trials (RCTs; 5230 participants), including lifestyle interventions focusing on physical activity and sedentary behavior in 12 studies, diet in six studies, and 36 concentrating on behaviorally-orientated treatment programs. Three types of drug interventions (metformin, orlistat, and sibutramine) were found in 10 studies. No surgical intervention was eligible for inclusion. The studies varied greatly in intervention design, outcome measurements, and methodological quality. Meta-analyses indicated a reduction in overweight at 6 months and 12 months follow up in: (1) lifestyle interventions involving children; and (2) lifestyle interventions in adolescents with or without the addition of orlistat or sibutramine. A range of adverse effects was noted in drug RCTs.24 As our society rapidly moves towards a higher level of obesity, implementing comprehensive and rapid interventions seems necessary, and the results of interventional researches might render valuable findings for health care planners and managers in order to approach this important issue.
Materials and methods Participants This intervention was performed from 2004 to 2006. Obese students (1st grade to 3rd grade) attending 12 public high schools and their parents (n Z 192), who had been identified in the previous study,3 were considered. Students consuming special diets, taking drugs affecting body weight, or students not complying with the intended conditions or criteria (due to the holidays or examination periods) were excluded from the research (n Z 40); consequently, 152 were included in the study. They all met the inclusion criteria, and were randomly assigned to either
Behavior modification in obesity the case or the control groups (n Z 76 in each group). The inclusion criteria consisted of: (1) absence of morbid obesity (hormonal disorders such as hypothyroidism, Cushing’s syndrome, etc.); (2) absence of weight-reducing diets or drugs affecting body weight; (3) participation of one parent (with a minimum educational level of 9th grade) in the study; (4) tendency of the students and parents to lose weight; (5) BMI 28 in the 1st grade students (15 years old), and BMI 29 in the 2nd grade and 3rd grade students (16 and 17 years old).25
Intervention The ‘‘behavior modification’’ interventional program was implemented by a nursing expert and a physical education expert for the participants (based on the compiled training booklets) as follows: (1) it comprises a 24-hour diet record for the students and their parents; (2) it provides faceto-face nutritional instructions for the parents supported by an educational booklet (during four 1-hour weekly sessions); (3) it provides face-to-face nutritional instructions for the students regarding dietary modification and techniques for increasing physical activity supported by an educational booklet (during eight 45-minute sessions, held twice a week); (4) it provides exercises demonstrated by the physical education expert at school in a group, 1 hour per day, 3 days per week, for 6 weeks. The exercise program consisted of warming up for 10 minutes, performing aerobic exercises for 40e45 minutes, and cooling down for 5e10 minutes, respectively, and included rapid and vigorous walking, running, rope jumping, zigzag movements, high-knees, butterfly movements, stepping exercises, and exercises for strengthening important muscles (e.g., the rectus abdominal, the quadriceps, the trapezius, and the latissimus dorsi). Because the research did not have any physical or mental adverse effects, the students and parents were allowed to voluntarily exit the research. The participants were reassured that the collected data would be kept confidential, and their identity and demographic characteristics would not be mentioned in the final report. The students and their parents completed informed consents to participate in the study. Moreover, the researchers tried to respect moral aspects (the control group was provided with educational booklets after data collection).
Outcome measures The students’ body weight (without wearing shoes or excess clothes) was measured before and after implementing the interventional program by the same individual (a nurse) using a Soehnle digital scale (Hamburg, Germany) to the nearest 0.1 kg; height was measured to the nearest 0.1 cm using a plastic measuring tape (while standing against the wall, without wearing shoes, and their occiputs and heels touching the wall); a level was placed on top of the head, parallel with the floor, to indicate the height on the measuring tape; BMI was calculated using the following equation: BMI Z weight (kg)/height (m)2; waist and hip circumferences were measured to the nearest 0.1 cm using a plastic measuring tape and the waist to hip ratio (WHR)
155 was calculated. Measurements were repeated 6 months after the intervention. Other data were collected using two questionnaires: a questionnaire for evaluating the demographic characteristics, medical history, and familial history of the students (including 13 questions), and a questionnaire for evaluating the parents’ personal characteristics and socio-economic status (including 23 questions), which were completed by interview. Students and parents’ nutritional knowledge was evaluated with 12 questions (with 1.5 points given to each correct answer) before and after implementing the interventional program. It was scored based on 12 multiple-choice questions including: the common features of diverse foodstuffs (e.g., Which food is similar to meat in terms of the nutrients?); food classification in terms of food category (e.g., Which food category does rice belong to?); and reason and necessity to use the four food groups [high-fat foods (chips), low-fat foods (baked chicken), obesity-inducing foods (ice cream), obesity-preventive foods (vegetables)]. The content validity was applied to confirm the validity, based on review of literature and nutritional specialists’ comments in this regard. Knowledge scores of < 7, 7e12, and 13e18 were considered poor, fair, and good, respectively. The cut-off point was determined on the basis of the knowledge mean standard deviation (SD). The questionnaire’s validity was determined using valid references and the opinions of 10 professors; its reliability was confirmed using the test retest method (r Z 0.85). Beck’s Standard Depression Questionnaire was completed before and after implementing the program for the intervention and control groups in order to screen the symptoms of depression. The questionnaire consisted of 21 items (each with five response categories), and the participants were required to chose only one correct answer; zero, one, two, and three points were assigned to the first, second, third or fourth, and fifth choices, respectively, and a total score of 0e15, 16e30, 31e46, and 47e63 were considered as normal, mild depression, moderate depression, and severe depression symptoms, respectively.26,27 The research objectives and potential complications of obesity were explained to attract the participation of students and parents.
Data analysis The collected data were analyzed using the SPSS software and descriptive statistical tests (mean, standard deviation, absolute and relative frequency); the paired t test was used for comparing BMI, body weight, height, waist circumference, hip circumference, and WHR; t test was used for comparing depression scores and the students’ and parents’ nutrition knowledge between the intervention and control groups. The Chi-square test was used for analyzing the symptoms of depression in both case and control groups.
Results One-hundred and fifty-two girls and boys of the 14e19 year age group (mean SD Z 15.87 1 years) enrolled in this study with 76 individuals in each of the intervention and control groups. Before implementing the interventional program, there were no statistically significant differences
156
T. Toulabi et al.
Table 1 Anthropometric measurements before and after implementing the ‘‘behavior modification’’ interventional program in the case and control groups of obese students of state high schools in Khorram Abad from 2004 to 2006. Variables
Height (m) Body weight (kg) BMI (kg/m2) Waist circumference (cm) Hip circumference (cm) WHR (%)
Before intervention
After intervention
Case
Control
p
Case
Control
p
1.65 0.08 81.67 10.94 30.43 2.39 99.25 7.73 109.3 6.41 0.90 0.04
1.67 0.09 84.43 10.79 30.33 1.93 100.19 9.7 109.96 5.82 0.90 0.04
0.135 0.119 0.769 0.513 0.667 0.902
1.67 0.08 77.50 12.46 27.51 3.18 96.23 9.50 105.18 7.38 0.91 0.06
1.69 0.09 83.51 11.79 29.15 2.74 100.40 6.99 109.80 6 0.90 0.05
0.368 0.003 0.001 0.003 0.001 0.935
BMI Z body mass index; WHR Z waist to hip ratio.
between the intervention and control groups with regard to BMI, body weight, waist circumference, and hip circumference, but the difference was statistically significant after implementing the interventional program, such that a significant reduction in BMI (p < 0.001), body weight (p < 0.003), waist circumference (p < 0.003), and hip circumference (p < 0.001) was found in the case group, thus the idea that the ‘‘behavior modification’’ interventional program affects BMI in the obese students of the public high schools was supported (p < 0.001), but there was no statistically significant difference in WHR (Table 1). The frequency of depression before the intervention was not statistically significant between the two groups; after intervention, the symptoms of mild and moderate depression decreased and the frequency of students without symptoms of depression increased in the intervention group, which did not reveal a statistically significant difference between the two groups (Table 2). Thus, the hypothesis that implementing the interventional program affects the frequency of the symptoms of depression was not supported. It is worth noting that adolescents actually had a good baseline “knowledge score” including > 80% in the intervention group, > 66% in the control group, and even better in the parents. Moreover, the difference in adolescents’ nutrition knowledge between the two groups at baseline was not statistically significant, but the difference in scores was statistically significant between the intervention and control group after the intervention (p < 0.003), such that good knowledge level was found to be more frequent in the case group (Table 3). Parents’ nutrition knowledge was not statistically significant different between the two groups at baseline,
but this difference was statistically significant after intervention (p < 0.046), such that good knowledge level was found to be more frequent in the case group (Table 4).
Discussion An important finding of this study was the effectiveness of ‘‘behavior modification’’ interventional program on BMI and the confirmation of the research hypothesis, which is consistent with the results of other researches. Although there is limited quality data to recommend one treatment program to be favored over another, the review of literature shows that combined behavioral lifestyle interventions compared to standard care or self help can produce a significant and clinically meaningful reduction in overweight in children and adolescents. Furthermore, high quality research that considers psychosocial determinants for behavior change, strategies to improve clinicianefamily interaction, and cost-effective programs for primary and community care are required.24 In a similar quasiexperimental research conducted in 2008, 53 obese adolescent girls participated in a behavior modification program, which lasted for 16 weeks (4 hours per week). The program included instruction in problem solving, stress management (yoga), healthy eating, physical behavior, and parent education. The study revealed that a behavioral modification program has a great effect on decreasing BMI. The research suggested that parents, school nurses, and other supporting groups should be encouraged to participate in this program. The results of this study were similar to our results.28 In Qi and Dennis’ study, it was found that the best method in controlling weight is the exact report
Table 2 A comparison between the percentages of symptoms of depression before and after the behavior modification interventional program in the case and control groups of obese students of state high schools in Khorram Abad from 2004 to 2006. Symptoms of depression
None Mild Moderate Data are presented as n (%).
Before intervention
After intervention
Case
Control
p
Case
Control
p
55 (36.2) 15 (9.9) 6 (3.9)
54 (35.5) 17 (11.2) 5 (3.3)
0.894
65 (42.8) 8 (5.2) 3 (2)
62 (40.8) 14 (9.2) 0 (0)
0.095
Behavior modification in obesity
157
Table 3 Absolute (relative) frequency distribution of students’ knowledge level regarding nutrition before and after implementing the interventional program in the case and control groups of obese students. Knowledge level
Fair Good Total
Before intervention
After intervention
Case
Control
p
Case
Control
p
15 (10) 61 (40) 76 (50)
25 (16.5) 51 (33.5) 76 (50)
0.182
4 (2.6) 72 (47.4) 76 (50)
18 (11.9) 58 (38.1) 76 (50)
0.003
Data are presented as n (%).
and writing of the consumed food type and amount.29 In our study, the participants wrote down the consumed foods during a 24-hour period, and the majority of individuals considered this method to be the most effective in controlling obesity. In another study, six schools were randomly selected, and the effects of physical activity, diet patterns, and selfimage on BMI were evaluated; the results of this study showed that the program had a beneficial effect on physical activity, diet patterns, and self-image of the female students; during the follow-up period, the participants showed behavioral changes and increased physical activity; thus, the researchers suggested that prolonged programs and further evaluations be performed for achieving the proposed objectives.30 The results of numerous researches have revealed that general physical activity, following a healthy and balanced diet, and reducing the calories consumed has a beneficial effect on controlling obesity and BMI.31,32 Changing lifestyle and dietary habits and behaviors may help change the effects of inappropriate diets and sedentary lifestyles. Controlling behavior, managing psychological stress, and taking advantage of social support systems could systematically modify obesity.23,33 About 2000 third-grade students from 41 elementary schools of seven different American and Indian societies participated in a random study. The primary objective of intervention was finding methods for acculturating the school-based interventional program, which provided healthy diets and, in turn, consisted of four sections, namely: physical activity, diet, curriculum-planning, and family involvement. The results of this study revealed that school-based primary prevention programs for obesity had beneficial effects.34 The results of a quasi-experimental study carried out in Tehran, Iran, did not show any significant differences between the BMIs of the adolescents’ in two group after intervention whereas a significant difference was found between mean nutritional knowledge score in the case
group before and after the intervention. In addition, no significant differences were found between the means of intake of dairy products, salty snack, sweets, carbonated beverages, and fast food in the case group after and before the intervention, and no significant difference was found between the intake mean of these food products in the control group before and after the intervention. The results of the study revealed significant differences between the mean time of weekly vigorous physical activity and TV watching in the case group before and after the intervention, whereas no significant differences were shown between mean times of these activities in the control group.18 In another study performed to determine the effects of interventional programs on body weight reduction and self esteem among 79 obese children in four different zones of the Education Department of Northern Tehran, a statistically significant difference was reported between the body weights of the two groups after implementing the interventional program, which was consistent with the results of the present study.11 In a nine-session semi-experimental interventional study performed on 26 obese students in Arizona for reducing body weight, the students’ body weight did not change, but their self esteem was elevated;17 other findings of this research revealed a reduction in waist and hip circumferences after implementation of the ‘‘behavior modification’’ interventional program; however, WHR did not reveal a statistically significant difference, which was not consistent with some studies11, 35 and was consistent with others.36 Thus, we suggest more extensive studies to be performed in this area. As the results of the present research showed, the symptoms of depression were reduced following the reduction of BMI and body weight, which was not statistically significant. The results of numerous studies have revealed that criticizing, insulting, and showing disrespect towards obese people causes them to feel isolated and depressed. Regarding the rapid progression in incidence rates of obesity in childhood and adolescence, and also the
Table 4 Absolute (relative) frequency distribution of parents’ knowledge level regarding nutrition before and after implementing the interventional program in the case and control groups of obese students. Knowledge level
Fair Good Total Data are presented as n (%).
Before intervention Case
Control
13 (8.6) 63 (41.4) 76 (50)
16 (10.52) 60 (39.48) 76 (50)
After intervention p
Case
Control
p
0.9
6 (3.9) 70 (46.1) 76 (50)
14 (9.2) 62 (40.8) 76 (50)
0.046
158 potential risks of obesity in adulthood, we recommend that obesity and its related complications should be strictly controlled with the participation of the parents and the school staff by preventing obesity at young ages and by changing and modifying diet patterns and lifestyle (via behavior therapy, eliminating non-nutritious snacks from the diet, showing appropriate TV advertisements, and encouraging vigorous and joyful physical activities, such as stretching, aerobic exercises, swimming, and basketball). These measures will significantly reduce health care costs. The ‘‘behavior modification’’ interventional program (including nutritional education, modifying and changing dietary habits, teaching exercise programs and their benefits to the students, teaching nutritional facts to the parents, and performing exercises 3 days a week) is effective in reducing BMI in obese students. Therefore, school principals and planners can play an important role in controlling obesity and its numerous potential complications by implementing this program via the students, their parents, and the school staff.
Acknowledgments The authors wish to thank the Education, Research, and Technology Deputy (Lorestan University of Medical Sciences) for funding the research, the staff of the Endocrinology and Metabolism Research Center (Tehran University) for their assistance in approving the proposal, Ms. Farzaneh Ravanshad, Ms. Elham Sheykhi, and Mr. Yadollah Pournia for the proofreading of the English version of the article, the students and their parents, and the staff of the Education Department of Khorram Abad, who helped to perform the present research. This trial was registered at Metabolism Research Center, Tehran University of Medical Sciences, Tehran under the number 578. The authors would also like to thank Farzan Institute for Research and Technology for technical assistance.
References 1. Firek Pedras M, Malecka Tendera E, Klimek K, Zachurzok Buczynska A. Influence of fat tissue distribution on metabolic complications in children and adolescents with simple obesity. Endokrynologia 2006;12:19e24. 2. Zenzen W, Kridli S. Integrative review of school-based childhood obesity prevention programs. J Pediatr Health Care 2009; 23:242e58. 3. Amini F, Toulabi T, Khosh Niyat M. Prevalence of obesity and its relation with lifestyle in high school students. 12th World Congress on Public Health, 2009, April 27eMay 1, Istanbul, Turkey. 4. Rankin J, Tennant PW, Stothard KJ, Bythell M, Summerbell CD, Bell R. Maternal body mass index and congenital anomaly risk: a cohort study. Int J Obes (Lond) 2010;34:1371e80. 5. Amini F, Toulabi T, Payamani Sh, Tarahi MJ. Investigating lifestyle as a method for preventing obesity in adolescents. Abstracts of articles presented in the Nationwide Congress on Chronic Diseases, March, 2005, Khorram Abad, Iran. 6. Li C, Engstrom G, Hedblad B, Calling S, Berglund G, Janzon L. Sex differences in the relationships between BMI, WHR and incidence of cardiovascular disease: A population based cohort study. Int Obesity 2006;30:1775e81.
T. Toulabi et al. 7. Merten MJ, Williams AL, Shriver LH. Breakfast consumption in adolescence and young adulthood: parental presence, community context, and obesity. J Am Diet Assoc 2009;109:1384e91. 8. Ritchie LD, Spector P, Stevens MJ, Schmidt MM, Schreiber GB, Striegel-Moore RH, et al. Dietary patterns in adolescence are related to adiposity in young adulthood in black and white females. J Nutr 2007;137:399e406. 9. Woodruff SJ, Hanning RM, Lambraki I, Storey KE, McCargar L. Healthy Eating Index-C is compromised among adolescents with body weight concerns, weight loss dieting, and meal skipping. Body Image 2008;5:404e8. 10. Singh AS, Mulder C, Twisk JW, van Mechelen W, Chinapaw MJ. Tracking of childhood overweight into adulthood: a systematic review of the literature. Obes Rev 2008;9:474e88. 11. Ghosh JR, Bandyopadhy AR. Comparative evaluation of obesity measures: relationship with blood pressures and hypertension. Singapore Med J 2007;48:232e5. 12. Gregory LB, Alain GB, Steven S, Russell T, Karol E, Roger S, et al. The impact of obesity on cardiovascular disease risk factors and subclinical vascular disease. Arch Intern Med 2008; 168:928e35. 13. Soham A, Kenneth JO, Kyriakos SM, Kuo YF, Karl E, James SG. The effect of obesity on disability vs mortality in older Americans. Arch Intern Med 2007;167:774e80. 14. Kenchaiah S, Evans JC, Levy D, Wilson PW, Benjamin EJ, Larson MG, et al. Obesity and the risk of heart failure. New Engl J Med 2002;347:305e13. 15. Zhao G, Ford ES, Dhingra S, Li C, Strine TW, Mokdad AH. Depression and anxiety among US adults: associations with body mass index. Int J Obesity 2009;33:257e66. 16. Andersen JR, Aasprang A, Bergshol P, Sletteskog N, Va ˚ge V, Natvig GK. Anxiety and depression in association with morbid obesity: changes with improved physical health after duodenal switch. Health and Quality of Life Outcomes 2010;8:52. 17. Tavakkoli M. Investigating the effects of an interventional program on weight reduction and self-esteem in obese students. A master’s degree dissertation of the Instructor Educating University, Tarbiat Modares University, 1995. 18. Azadi A, Anousheh M, Alhani F, Hajizadeh E. The effect of implementation of health promotion program in school to control risk factors for obesity in adolescents. Iranian South Medical Journal 2009;11:153e62. 19. Tormo MJ, Navarro C, Chirlaque MD, Barber X, Argilaga S, Agudo A, et al. Physical sports activity during leisure time and dietary intake foods and nutrients in a large Spanish cohort. Int J Sport Nutr Exerc Metab 2003;13:47e64. 20. Alfano CM, Klesges RC, Murray DM, Beech BM, McClanahan BS. History of sport participation in relation to obesity and relate health behaviors in women. Prev Med 2002;34:82e9. 21. Harris MB, Sutton M, Kaufman EM, Carmichael CW. Correlates of success and retention in a multifaceted, long-term behavior modification program for obese adolescent girls. Addict Behav 1980;5:25e34. 22. Bary GA. Behavior modification in the treatment of obesity. UpToDate 2003;11:1e2. 23. Phelan S, Wadden TA. Combining behavior and pharmacological treatments for obesity. Obesity Res 2002;10:560e74. 24. Oude Luttikhuis H, Baur L, Jansen H, Shrewsbury VA, O’Malley C, Stolk RP, et al. Interventions for treating obesity in children. Cochrane Database Syst Rev 2009;1:CD001872. 25. Azizi F. Tehran lipid and glucose study. Tehran: Shahid Beheshti University Press; 2001. 26. Moutavi F. The central office of the health ministry, normalization of Beck’s depression questionnaire. Tehran: Shahid Beheshti University Press; 2002. p. 6e9. 27. Fathi Ashtiani A. The psychological tests of personality assessment and emotional health. 1st ed. Tehran: Bessat Press; 2009. p. 67e71.
Behavior modification in obesity 28. Sabet-Sarvestani R, Kargar1 M, Kave MH, Tabatabai HR. The effect of dietary behavior modification on anthropometric indices in obese adolescent female students. Iran J Pediatr 2008; 18:71e6. 29. Qi BB, Dennis KE. The adoption of eating behaviors conducive to weight loss. J Eating Behav 2000;1:23e31. 30. Tan D, Zwar NA, Dennis SM, Vagholkar S. Weight management in general practice: what do patients want? Med J Aust 2006;185: 73e5. 31. Zalilah MS, Khor GL, Mirnalini K, Norimah AK, Ang M. Dietary intake, physical activity and energy expenditure of Malaysian adolescents. Singapore Med J 2006;47:491e8. 32. Anding JD, Suminski RR, Boss J. Dietary intake, body mass index exercise and alcohol: are college women following the dietary guide lines for Americans. J Am Coll Health 2001;49: 167e71.
159 33. McMillan-Price J, Petocz P, Atkinson F, O’neill K, Samman S, Steinbeck K, et al. Comparison of 4 diets of varying glycemic load on weight loss and cardiovascular risk reduction overweight and obese young adults: a randomized controlled trial. Arch Intern Med 2006;166:1466e75. 34. Nyamdori R, Qiao Q, Soderberg S, Pitkaniemi J, Zimmet P, Shaw J, et al. Comparison of body mass index with waist-to-hip ratio and waist-to-stature ratio as a predictor of hypertension incidence in Mauritius. J Hypertens 2008;26:866e70. 35. Koch E, Bogado M, Araya F, Diaz C, Manriquez L, Parades M, et al. Impact of parity on anthropometric measures of obesity controlling by multiple confounders. J Epidemiol Com Health 2008;62:461e70. 36. Napolitano MA, Foster GD. Depression and obesity: implications for assessment, treatment and research. Clin Psychol Sci 2008;15:21e7.
