L. Vlasyk¹, A. Sukholotiuk¹, T. Khrystych²,

¹ HSEE of Ukraine "Bukovinian State Medical University", Chernivtsi, Ukraine

² HSEE of Ukraine "Yurii Fedkovych Chernivtsi National University", Chernivtsi, Ukraine

ABSTRACT. Introduction. Excessive body weight and obesity account for 5 % of world deaths. The cessation of diabetes and obesity prevalence growth by 2025 is one of 9 voluntary global targets to struggle with noncommunicable diseases.

Aim. To put forward ways to increase the effectiveness of health services in the area of nutrition control, physical activity and body weight.

Materials and Methods. The experience of conducting individual prophylactic consultations of patients with overweight on the basis of a municipal policlinic and a private medical center has been used. 377 adult residents of Chernivtsi region have been interviewed in public places of the city during educational events. Bibliosemantic, sociological and statistical methods have been used.

Results and Discussion. The ways to increase the effectiveness of body mass control services, which are recommended for use at the level of primary care, are analyzed in the article. The proposed method for assessing the risk of developing obesity using bioimpedance analysis of the body composition, which can serve as a tool for doctors to provide reasonable observation of different patients: with an burdensome heredity for arterial hypertension and diabetes mellitus; with disturbed eating behavior; with concomitant diseases limiting the intensity of their physical activity; with the problem of accumulation of visceral fat. In all cases, body mass control showed sufficient motivation of the patients to achieve the target result.

Conclusions. Increasing the effectiveness of body mass control services provided to patients at the level of the primary care is possible using an integrated approach and risk assessment in the dynamics. The above examples show that taking into account the dynamics of indices of bioimpedance analysis in risk assessment provides reasoned management of patients motivated to achieve the target results. The effectiveness of consultations is enhanced by the use of written recommendations and modern communication methods.

Key Words: body weight control, obesity, primary health care, integrated approach, risk assessment.

Introduction. In Europe, there is a high prevalence of noncommunicable diseases (NCD), which contribute to 77 % of disease burden and to almost 86 % of premature mortality. Global recommendations to combat the epidemic of cardiovascular disease, cancer, chronic respiratory disease and diabetes involve strategies aimed at reduction of behavioural risk factors both on a population level and the level of an individual [1]. Global risk factors include obesity and excessive body weight, which contribute to 5 % of deaths worldwide. “A 10 % relative reduction in the prevalence of insufficient physical activity” and “halt the rise in diabetes and obesity” by 2025 are high-priority of nine voluntary global NCD targets. The advantages of developing the potential and the capacities of healthy behaviours population outreach belong to health care institutions; this was the topic of the conference of the European НЕРА network (Health-Enhancing Physical Activity) (Zurich, 2014) [2]. The significance of primary healthcare in halting the prevalence of the main NCD risk factors is also upheld by the documents of WHO Regional Office for Europe, namely in the European Food and Nutrition Action Plan 2015–2020 [3] and in the Physical activity strategy for the WHO European Region 2016–2025. [4]. A conceptual reference point for inclusion of services related to nutrition counselling, physical activity and control of body weight into the scope of primary care is provided by the European Framework for Action on Integrated Health Services Delivery (EFFA IHSD). However, as of now, this work has not generated any perceptible results. The level of the involvement to preventive technologies remains low and the quality of services rendered to the patients remains unsatisfactory as well. The WHO Regional Office for Europe emphasizes three questions that need to be answered: the efficiency of services provided by primary care physicians concerning physical activity and body weight control; the challenges faced by the primary healthcare in providing such services and the immediate actions to be taken to improve the conditions for rendering such services [5].

Objective of the study. To suggest methods to increase the effectiveness of preventive interventions in control of nutrition, physical activity and body weight.

Materials and methods. This study has used WHO regulatory documents and the experience of individual prophylactic health counselling at the premises of a municipal polyclinic and a private medical centre. The authors have polled 377 adult residents of Chernivtsi region during public outreach health campaigns. A referential and semantic method, a sociological method and a statistical method were used in the study.

Results. According to WHO global data, 39 % of adults over 18 years of age have excessive body weight and approximately 13 % have obesity. Excessive body weight and obesity are serious alimentary problems, associated with premature death, increased risk for cardiovascular disease, diabetes, cancer and other hazardous conditions. According to the results of our survey, only 65 (17.24 %) respondents (n = 377) admitted (as a self-assessment) to have excessive body weight, among them 21 (13.04 %) males and 44 (20.37 %) females. Having doctor’s consultations on healthy lifestyles was reported by 32 respondents (60.38 %) (n = 53), of these 23 (71.88 %) were consulted on their eating and 16 (50.0 %) on their physical activity; 14 respondents (43.75 %) were consulted on eating and physical activity combined. However, only one-third of respondents followed the recommendations and approximately half of respondents took them into consideration. No significant difference was found between individuals with excessive body weight and individuals with normal body weight regarding the frequency of consultations obtained. However, current guidelines provide that every patient’s visit to a healthcare institution is a chance for the physician to assess behaviour-based individual risk taking into consideration the interconnected risks. Risk assessment should be coupled with practical suggestions on risk control. Doctor’s information should be credible and motivate the patient for change. Recommendations should be convincing and sound (based on the findings of patient-appropriate diagnostic and preventive tests or measurements) [6].

To diagnose obesity and excessive body weight in adults, body mass index (BMI) is used, calculated as the ratio of body weight (in kilograms) to the square of height (in meters). According to the WHO, the diagnosis of excessive body weight or obesity is made in the following cases: BMI ≥ 25: excessive body weight; BMI ≥ 30: obesity. BMI is the most convenient tool to diagnose obesity and excessive weight in the population (the same for people of both genders and for all age groups of adults). However, BMI is a general guide, since it may reflect different levels of body fat in different people. With age, the distribution of fat in the body changes. Athletes may have higher than normal body weights with normal levels of body fat (i.e. higher lean mass). On the other hand, the percentage of fat in people with normal body weight may exceed established norms, which is a health threat, especially if excessive fat between internal organs (visceral fat) is concerned. It is increased visceral fat that triggers the risk of cardiovascular disease and diabetes. We have suggested a method to assess the efficacy of excessive body weight control and to determine obesity risk by appending BMI with bioelectrical impedance analysis. Fat mass percentage, visceral body fat and physical type were assessed on a point-based scale; a composite score was used to assess the efficacy of excessive body weight control and obesity risk.  This method was successfully tested during periodic health screening in a polyclinic and in a private clinic as a part of the services of a dietitian and a general practitioner in Chernivtsi. Almost 10 years of experience of its use allowed proposing an optimal method to assess for excessive body weight and the risk for obesity and the efficacy of corrective interventions. The method is employed in the following way: During the physical examination of the patient, the health professional measures height and body weight. BMI = body weight (kg)/ height (m) squared. When excessive body weight is found, i.e. BMI 25–30 kg/m², bioelectrical impedance analysis is performed, i.e. weighing the patient on TANITA digital scales, which is used to determine body fat (%), visceral fat (%) and physical activity type (ratio of fat to muscle). Using Table 1, calculate the score for each parameter: Scores = (F – N) x k, where F = actual value of the parameter (at F>N); N = normal; k = the appropriate factor.

Table 1

Assessment of excessive body weight and the risk for obesity

Then, the total of the obtained scores is used to assess the efficacy of excessive body weight control (using Table 2) and the risk of obesity in excessive body weight (using Table 3).

Table 2

Efficacy assessment of excessive body weight control

Table 3

Assessment of obesity risk in excessive body weight

Efficacy of control was evaluated in 3 months and in 6 months. If control was ineffective, the patient will have a repeat 6-month course.

Examples of practical use of the method for obesity risk assessment.

Example 1. Patient M (male). Age: 24 years. Height: 182 cm Body weight: 101 kg BMI: 29.89 kg/m² (99 ÷ [1.82 × 1.82]). Body fat: 28.3 % Visceral fat: 9 % Body type 2. The patient has a family history of hypertension and diabetes. In terms of nutritional status, the patient has excessive body weight and a high obesity risk: BMI: 29.89 – 25 = 4.89; 4.89 × 2.00 = 9.78 points; Body fat: 28.3 – 19 = 9.3; 9.3 × 1.7 = 15.81 points; Visceral fat: 9 % = 0 points; Body type 2 = 10 points; Total score: 35.59 points. Recommendations for the patient included non-drug control of excessive body weight according to the Unified clinical protocol of primary, secondary (specialized) and tertiary (highly specialized) healthcare and medical rehabilitation. Prevention of cardiovascular disease [7]. Efficacy evaluation of interventions was performed in 3 months: body weight: 94.3 kg; BMI: 28.47; body fat: 23.8 %; visceral fat: 7 %; physical type: no changes. Calculation of obesity risk: BMI 28.47 – 25 = 3.47; 3.47 × 2.00 = 6.94 points; fat level 23.8-19 = 4.8; 4.8 × 1.7 =  8.16 points; visceral fat 7 %: 0 points; physical type 2 = 10 points. Total: 25.1 points. The control was insufficient. High obesity risk remained. The patient was given recommendations on physical activity (the patient is an office worker). The effectiveness of interventions was evaluated in 6 months: body weight: 92.7 kg; BMI: 27.99; body fat: 21.0 %; visceral fat: 6 %; physical activity type: 2. Calculation of obesity risk: BMI 27.99 – 25 = 2.99; 2.99 × 2.00 = 5.98 points; body fat 21.0 – 19 = 2; 2 × 1.7 = 3.4 points; visceral fat 6 % = 0 points: physical type 2 = 10 points. Total: 19.38 points. Obesity risk: moderate. Control: insufficient (see Table 4). The patient was referred to a dietitian for consultation; additional recommendations to increase the intensity of physical activity were given. Control: in 3 months.

Table 4

Efficacy assessment of excessive body weight control in male patient M.

Example 2. Patient Sh. (female). Age: 35 years. Height: 163 cm. Body weight: 76.3 kg. BMI: 28.7 kg/m² (76.3 ÷ [1.63 × 1.63]). Body fat: 34.4 %. Visceral fat: 6 %. Physical type: 3. The patient reports weight gain after she delivered a child and no family history of associated disease. In terms of nutritional status, the patient has excessive body weight and a moderate obesity risk: BMI 28.7 – 25 = 3.7; 3.7 × 2.00 = 7.4 points; body fat 34.4 – 32 = 2.4; 2.4 × 1.43 = 3.4 points; visceral fat 6 % = 0 points; physical type 3 = 10 points. Total: 20.8 points. Recommendations for the patient included non-drug control of excessive body weight. Efficacy evaluation of interventions was performed in 3 months: body weight: 71.0 kg, BMI: 26.7; body fat: 32.5 %; visceral fat and physical type: no changes. Calculation of obesity risk: BMI 26.7 – 25 = 1.7; 1.7 × 2.00 = 3.4 points; body fat 32.5 – 32 = 0.5; 0.5 × 1.43 = 0.7 points; visceral fat 6 % = 0 points; physical type 3 = 10 points. Total: 14.1 points. The control was effective. Moderate obesity risk remained. The patient was given recommendations to increase the duration and intensity of physical activity. The effectiveness of interventions was evaluated in 6 months: body weight: 67.2 kg; BMI: 25.3; body fat: 31.4 %; visceral fat: 5 %; physical activity type: 5. Calculation of obesity risk: BMI 25.3 – 25 = 0.3; 0.3 × 2.00 = 0.6 points; body fat = 0 points; visceral fat = 0 points; physical type 5 = 0 points. Total: 0.6 points. Obesity risk: low. The control was effective (see Table 5). The patient was given recommendations for supportive treatment and follow-up in 6 months.

Table 5

Efficacy assessment of excessive body weight control in female patient Sh.

Example 3. Patient B. (female). Age: 69 years. Height: 165 cm. Body weight: 81.5 kg. BMI: 29.9 (81.5 ÷ [1.65 × 1.65]). Body fat: 39.8 %. Visceral fat: 12 %. Physical type: 3. The patient has coronary artery disease and moderate secondary hypertension. In terms of nutritional status, the patient has excessive body weight and a high obesity risk: BMI 29.9 – 25 = 4.9; 4.9 × 2.00 = 9.8 points; body fat 39.8 – 35 = 4.8; 4.8 × 1.43 = 6.9 points; visceral fat 12 % = 0 points; physical type 3 = 10 points; Total: 26.7 points. Recommendations for this patient included non-drug control of excessive body weight.  Efficacy evaluation of interventions was performed in 3 months: body weight: 80.8 kg, BMI 29.7; body fat 37.9 %; visceral fat and physical type: no changes.  Calculation of obesity risk: BMI 29.7 – 25 = 4.7; 4.7 × 2.00 = 9.4 points; body fat 37.9 – 35 = 2.9; 2.9 × 1.43 = 4.1 points; visceral fat 12 % = 0 points; physical type 3 = 10 points. Total: 23.5 points. High risk of obesity was reduced to moderate risk of obesity. The control was insufficient. The patient was given a detailed explanation of the principles of healthy eating and to increase the duration of her physical activity moderately. Efficacy evaluation of interventions was performed in 6 months: body weight: 78.2 kg; BMI: 28.7; body fat: 37.0 %; visceral fat: 12 %; physical activity type: 3. Calculation of obesity risk: BMI 28.7 –25 = 3.7; 3.7 × 2.00 =  7.4 points; body fat: 37.0 – 35 = 2.0; 2.0 × 1.43 =  2.9 points; visceral fat = 0 points: physical type 3 = 10 points. Total: 20.3 points. Obesity risk: moderate. The control was ineffective. It was recommended to extend control for another 6 months (Table 6).

Table 6

Efficacy assessment of excessive body weight control in female patient B.

Example 4. Patient G. (male). Age: 70 years. Height: 178 cm. Body weight: 84.7 kg. BMI: 26.7. Body fat: 25.2 %. Visceral fat: 14 %. Physical type: 2. Patient’s usual lifestyle was active. In terms of nutritional status, the patient has excessive body weight and a moderate obesity risk: BMI 26.7 – 25 = 1.7; 1.7 × 2.00 = 3.4 points; body fat 25.2-25 = 0.2; 0.2 × 1.7 =  0.3 points; visceral fat 14 % = 4 points; physical type 2 = 10 points. Total: 17.7 points. Recommendations for this patient included non-drug control of excessive body weight. Efficacy of interventions was evaluated in 3 months: body weight: 83.9 kg, BMI 26.5; body fat 23.4 %; visceral fat: 14 % and physical type: 5.  Calculation of obesity risk: BMI 26.5 – 25 = 1.5; 1.5 × 2.00 = 3.0 points; body fat 0 points; visceral fat 14 % = 4.0 points; physical type 5 = 0 points. Total: 7.0 points. The control was effective. Obesity risk: low. An elevated level of visceral fat remains. The recommendations for the patient included limiting saturated fats, complete exclusion of food industry trans-fats and maintaining an adequate level of physical activity. Efficacy evaluation of interventions was performed in 6 months: body weight: 80.5 kg; BMI: 25.4; body fat: 22.2 %; visceral fat: 13 %; physical activity type: 5. Calculation of obesity risk: BMI 25.4 – 25 = 0.4; 0.4 × 2.00 = 0.8 points; body fat = 0 points; visceral fat = 2 points; physical type 5 = 0 points. Total: 2.8 points. Obesity risk: low. The control was effective (see Table 7).

Table 7

Efficacy assessment of excessive body weight control in male patient G.

Discussion

The increasing global problems of excessive body weight and obesity should evoke the global medical community to implement active prophylactic actions. However, in a survey of the adult population, we have not found any significant differences concerning medical recommendations for healthy lifestyles (including dietary patterns and physical activity) between the respondents aware of their excessive weight and the respondents who considered their body weights normal. Moreover, only a third of respondents adhere to doctor’s recommendations and approximately half only takes them into consideration. Similar findings have been reported in other studies of eating behaviours of the adult population [8]. In order to increase the effectiveness of weight control services, the commitment of physicians and patients to individualized prophylactic patient counselling in healthy eating and physical activity. The role of physicians in such counselling is well-studied as part of prevention of cardiovascular disease in adults. As reported in the literature, medium- and high-intensity counselling increased the patients’ activity by 40 minutes in 1 week. Low-intensity nutrition counselling increased the consumption of vegetables and fruits up to two servings a day. The researchers believe that medium- and low-intensity counselling are best suited for the primary care level [9]. It is important to combine these with other types of patient support (scheduled nursing supervision; group sessions, e.g. health schools; web-based counselling, etc.). Multifaceted services are more effective than individual ones. It is important to monitor and to evaluate physical activity with due utilization of special movement-measuring equipment. Fitness apps and accessories such as bracelets, clips and sensors have empowered a smartphone, making it more than just a step-measuring instrument [10]. Overweight patients may be interested in controlling changes in their obesity risks. The method for risk assessment suggested by the authors (taking into consideration how bioelectrical impedance analysis change with time) provides the physician with an instrument for evidence-based monitoring of patients, which vary in their age, gender, family history and concomitant disease. Thus, we have accumulated experience of managing young office workers with excessive body weight, high risk for obesity and family history of hypertension and diabetes (Example 1); young postpartum women with impaired eating behaviours (Example 2); elderly patients requiring longer interventions to control their body weight because of comorbidities, which limit the intensity of their physical activity (Example 3) and the patients whose activity and mobility is not limited, but with a problem of excessive visceral fat (Example 4). In all the cases of body weight control, the patients were found to have sufficient motivation to achieve a target result.

Conclusions

1. The suggested method to assess the efficacy of interventions used to control excessive body weight and risk for obesity was employed for the purposes of controlling prophylactic interventions in patients with different age, gender and comorbidities.
2. Examples are given to show that taking into account changes in parameters of biological impedance analysis for risk assessment ensures evidence-based management of patients motivated to attain their target results.
3. Counselling is more productive when written recommendations and modern communication methods are used.

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Надійшла до редакції 18.04.2019 р.