Lipid Profile Improvement after Four Group Psychological Interventions in Combination to Nutritional and Physical Activity Instructing Among Overweight and Obese Individuals.

0.44 MB·English

by  AGAH HERIS, Mojgan

Original Article
Iranian J Publ Health, Vol. 42, No.1, Jan 2013, pp.86-95

Lipid Profile Improvement after Four Group Psychological Interventions
in Combination to Nutritional and Physical Activity Instructing Among
Overweight and Obese Individuals

*Mojgan AGAH HERIS 1, Ahmad ALIPOUR 1, Masoud JANBOZORGI², Reza HAJIHOSSEINI 3,
Farhad SHAGHAGHI 1, Neda GOLCHIN 1, Shahnaz NOUHI 1

1. Dept. of Psychology, School of Human Sciences, Payam e Noor University, Tehran, Iran
2. Dept. of Psychology, Research Institute of Hawzah and University, Ghom, Iran
3. Dept. of Biochemistry, School of Basic Sciences, Payam e Noor University, Tehran, Iran

*Corresponding Author: Tel: [phone] Email: [email protected]

(Received 28 Sep 2012; accepted 16 Dec 2012)

Abstract
Background: Research background approved weight loss would result in improvement of lipid profile. Nowadays,
weight management is attained by modifying psychological mediators, as well as dieting and making individuals do
more physical activity. Hence, This research was performed to compare effectiveness of different psychological inter-
ventions on lipid profile improvement among individuals with overweight and obesity.
Methods: Using quasi- experimental design, 68 participants with mean age 26 years and 9 months (ranged from 20 to
43) were randomly assigned into 4 groups (including LEARN, CBT, CT, and MCT), and eventually 61 participants
completed the treatment protocols. BMI was calculated by Omron digital body composition instrument, and blood
lipids and glucose concentrations were measured prior to and after all interventions.
Results: Data analysis by using t- test for dependent groups analysis revealed lipid profile, FBS, and BMI were signifi-
cantly modified after applying 4 interventions comparing baseline and post treatment mean differences(P<0.05). Fur-
thermore, repeated measure design analysis showed there were significant mean differences (P<0.05) in HDL choles-
terol, TG levels and FBS levels among 4 groups. Scheffe test revealed more detailed significant differences among four
groups in HDL cholesterol, and FBS concentration varieties (P<0.05).
Conclusions: Adding psychological interventions to dietary plans and regular physical activities in overweight man-
agement would consider as a valuable step in optimizing physiological outcomes and that’s because of correcting
mind- body interactional pathways among obese and overweight individuals.

Keywords: Lipid profile, Psychological interventions, BMI, Overweight, Obesity

Introduction

Obesity and overweight participate in chronic especially among women than men among Iranian
diseases such as diabetes, cancers, and coronary adults (6) and WHO predicts there will be entirely
heart disease, dyslipidemia etc (1, 2); these 1.5 billion overweight people in 2015 throughout
phenomena seriously threaten general health (1, 3, the world (7).
4). The prevalence of overweight (BMI≥25) and In addition to tragic statistic reported above,
obesity (BMI ≥30) are respectively 66%, and 33% excess body weight is related to harmful changes
(about 70 million people) among adult population in the blood lipid profile (8). Hence, triglyceride
in the United States (5), and obesity rate is 21.5% (TG) and cholesterol levels are higher in
among Iranian adults (6), these rates are higher overweight people than normal weight individuals
86 Available at: http://ijph.tums.ac.ir
Agahheris et al.: Lipid Profile Improvement after Four Group Psychological

(9). Consequently, weight loss tends to improve signed to LEARN, cognitive behavior therapy
the blood lipids concentrations (10-12). (CBT), cognitive therapy (CT), or metacognitive
Weight loss attained by regular physical activity, therapy (MCT) groups. Those in LEARN and
and declining fat intake from daily diets would re- CBT groups received treatment over 24 weeks,
sult in increasing HDL concentrations and im- whereas CT and MCT groups took 12 weeks
proving blood fat concentrations (10-13). It treatment. Two later groups (i.e. CT and MCT
straightforwardly associates with dietary habits (14- groups) did not receive further treatment until the
16), eating beliefs (17), physical activity (18), life end of the two other group interventions except
style (19) and fat intake (15, 16, 18), which can be to stay in their diet plan and physical activity (i.e.
influenced by psychological interventions. The ob- LEARN and CBT groups).
jective of these interventions is to change behaviors, The present study was approved by the Ethical
maladaptive beliefs (15, 20) and metacognitive be- Committee of the Behavioral Science Center of
liefs (21) as it is used for palliating or curing chron- Shahid Beheshti University of Medical Sciences in
ic conditions (22) such as overweight and obesity Iran.
(15, 16, 20). These conditions improvements would
Subjects
accelerate the weight loss process (15, 16). Psycho-
logical interventions, and mental health programs Announcing to different faculties of Payame Noor
accompanied by healthy diet plans and exercise University, and Health Centers of Tehran Munici-
programs tends to help people to identify their pality; 400 participants contacted us directly and
emotional and environmental aspects for and were offered an assessment interview, and those
against exercise behaviors and healthy eating pat- were eligible to take part in research if they met
terns (23-25). This interventions consists of self the following criteria: 1) female, 2) aged between
monitoring practices (15, 16, 20), problem solving 20 and 45 years (i.e. prior to menopause), 3)
skills (15, 20, 26), relapse prevention training (15, BMI> 25, 4) available for the period of treatment,
16, 26), paying attention to motivational aspects (15, 5) negative for C- reactive protein CRP), 6) willing
27), encouraging to compliant of the program. to participate in the study, 7) non- smokers. The
Confirming and gratifying the achievements (15, exclusion criteria were: 1) major medical or psy-
27), and improving eating and exercise self- efficacy chiatric illness (including diabetes, auto immune
(28, 29), etc. disease, cancer, cardiovascular problems, obses-
In respect of above points, training obese and over- sive compulsive disorder, bipolar disorder, and
weight individuals to modify their eating behaviors etc), 2) current psychiatric or psychological treat-
and beliefs in company with restricting daily fat in- ment, 3) weight loss of 10% or more within the
take from diet would be an essential constituent to previous six months prior to treatment, 4) dis-
improve serum lipid abnormalities. Thus, this re- orders or treatments known to affect eating,
search was aimed to investigating the effectiveness weight or metabolic rate, 5) disorders in which
of 4 psychological interventions in company with calorie or fat restriction are contraindicated, 6)
modifying eating diets to improve BMI, FBS, and binge eating is diagnosed by psychiatrist or health
lipid profile among obese and overweight Iranian psychologist, 7) taking obesity pharmacotherapeu-
females. tic agents and/ or herbal preparations for any
trial weight change. Eventually, according to sam-
Materials and Methods ple size in previous studies (e.g. 30), and sample
size determination guidelines by Length (31) for
Study design
repeated measure design analysis, 68 participants
This study was conducted in 2011. According to
met the criteria- they were allocated randomly into
quasi- experimental design, sixty eight volunteer
4 groups including LEARN, Cognitive behavior
women with body mass index (BMI, weight in kg/
therapy (CBT), Cognitive therapy (CT), and Meta-
height in m2) over than 25 were randomly as-
cognitive therapy (MCT). Written consents had
Available at: http://ijph.tums.ac.ir 87
Iranian J Publ Health, Vol. 42, No.1, Jan 2013, pp. 86-95
been informed out because of the exact nature of induce weight loss of 0.5–1 kg per week (32). The
the study, including the purpose, the course, and LCD should be higher in carbohydrates (55% or
the potential risk of the study. Eventually, 4 par- more of total calories), with generous portions of
ticipants of LEARN group, and 3 participants protein (15% of total calories). Fat content should
from MCT group dropped out during the first and not exceed 30% of total calories with no more
second sessions of treatment (4 of them got preg- than 8–10% of total calories coming from satu-
nant, and 3 does not willing to initiate the struc- rated fats (33). A registered dietitian arranged the
ture). So, 61 participants completed treatment weekly food plans respecting to LCD, BMI, RM,
protocols. age, gender, physical activity rate, total energy ex-
penditure, and the food interests applying FAVA
Anthropometrical measurement
professional nutrition software up to the end of
Height was measured in centimeters without the treatments.
shoes to the closest 0.5 cm. using a height rod on
a standard spring scale. Body weight (kg), BMI Physical activity
(kg/m2), and metabolism rate (RM; kcal) were Participants recorded the type and duration of dai-
measured using a digital body composition moni- ly physical activity in a daily activity diary which
tor (Omron BF-500, accuracy rate was 100 g) in were designed by research group at baseline and
street clothes without shoes. over the course of treatments. The physical activ-
ity goal was 30-60 minutes of moderate intensity
Glucose and lipid measurements
at least three times per week or walking 6000 steps
Blood samples were collected after 12 hours of per day (15, 16, 27) over through the treatments.
fasting (overweight), and were centrifuged within So, the participants were trained to walk 30-60
2 hours of sampling. The levels of serum total minutes a day and use a pedometer to record their
cholesterol, triglyceride (TG), and High- density steps per day.
lipoprotein cholesterol (HDL) were assessed by
the enzymatic method using Pars Azmoon Kits Psychological interventions
(Tehran, Iran). Low- density lipoprotein choles- Two members of the research team, one a regis-
terol (LDL) and fast blood sugar (FBS) were as- tered dietitian and the other a psychologist were
sessed by method using Pars Azmoon Kits (Te- instructed attended weekly group management
hran, Iran). Dietary assessments Participants were meetings for all 4 interventions throughout the
instructed to record their food intake over a week study. These interventions were instructed under
in a day diary record form (including ingredients the supervision of the expert clinicians who were
and calories) at baseline for estimating total calo- the advisors of this research.
ries intake from carbohydrates, fats, and proteins,
and their routine diet plans. They stayed in record- (1) Group LEARN program for weight
ing food intake to the end-up of this trial. management
LEARN which has an educational structure was
Diets and nutritional education designed by Brownell (16) in which the learner
The participants instructed to follow Low calorie
diets (LCD) were designed to create an energy (m)), and PA stands for the “physical activity” value
deficit of 500–1,000 calories a day (i.e. less than appropriate for the age and physiological state, For
total energy expenditure (kcal) per day)) which above females PA value in different states are estimat-
ed by these coefficients: Sedentary=1.00, Low active=

1.16, Active=1.27, and Very active= 1.44 (adapted

For females with age equal or more than 19 years old from: Institute of Medicine. Dietary Reference Intakes for
and BMI≥ 25 (e.g. overweight/obese), estimated ener- Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol,
gy requirement calculations formula is 448 − (7.95 × Protein, and Amino Acids (Macronutrients). Washington,
age (y)) + PA* × (11.4 × weight (kg) + 619 × height DC: National Academies Press; 2005.).
88 Available at: http://ijph.tums.ac.ir
Agahheris et al.: Lipid Profile Improvement after Four Group Psychological

masters crucial information for everyday life. The were being held weekly. Full details of this pro-
words LEARN is an acronym produced from the gram have been published elsewhere (27, 34, 35).
first letters of the five essential components of the
weight management: 1) Lifestyle, 2) Exercise, 3) (3) Group metacognitive therapy (MCT)
Attitudes, 4) Relationships, and 5) Nutrition. This The authors have designed this program by adapt-
program address some behavioral techniques in- ing from a program was recommended by Cooper,
cluding analyzing the behavior chains, internal at- Todd, and Wells (26) for treating bulimia nervosa
titude traps, negative self- talks, triggers for eating, and binge eating. This treatment by tackling en-
ABC approach( antecedent events, behavior, and gagement and motivation for weight loss, case
consequences), self- monitoring, set realistic goals, formulation and socialization to MCT model,
programmed activity, activity guidelines, flexible teaching attention and detached mindfulness
goals, habit change, select a support person, dis- strategies, addressing negative beliefs about eating:
tinguish craving from hunger, values of foods, uncontrollability and consequences, and positive
balanced diet, eating patterns, etc. This program beliefs about eating, negative self beliefs; chal-
comprised 16, 90- min sessions were being held lenges the barriers of weight loss, thinking modes,
weekly. Full details of this program have been self- awareness, executive control and intentional
published elsewhere (16). flexibility, the cognitive intentional syn-
drome(CAS), metacognitive beliefs, and object
Group cognitive behavior therapy (CBT) and metacognitive modes in individuals with over-
Cooper, Doll, Hawker, Byrne, Bonner, Eeley, weight and obesity. This treatment comprised 12,
O’Connor, and Fairburn (20) designed a long- 90- min sessions were being held weekly. Full de-
term cognitive behavior program to address cer- tails of this program will be published (26, 36).
tain psychological processes that interfere with
weight maintenance. This program includes some Statistical methods
cognitive and behavioral techniques to attain op- Mean differences between categories of lipid pro-
timal weight loss, to minimize subsequent weight file and BMI into 4 groups were tested by re-
regain, to distinguish between weight loss and peated measure design and mean differences be-
weight regain, to address potential obstacles, to tween baseline treatment and post- treatment were
the acceptance of maintenance, to educate prob- tested by paired sample t- test. P-value below 0.05
lem- solving process, to tackle body image con- was considered statistically significant.
cerns, to acquire and practice the behavioral skills
Results
and cognitive responses that are crucial for weight
control. This program comprised 24, 90- min ses-
sions were being held weekly. Full details of this After baseline testing regarding to BMI>25, 68
program have been published elsewhere (20). participants were randomly assigned into 4 groups
(each group consists of 17 subjects), and 61 com-
(2) Group cognitive therapy (CT) pleted a special protocol respecting to the group.
Beck (31, 34) has designed this program for mak- Mean age was 26 years and 9 months (ranged
ing obese and overweight people think like a thin from 20 to 43). T- test for dependent groups anal-
person. Hence, this program is on the basis of ysis to compare baseline and post treatment mean
cognitive restructuring and addresses motivational differences revealed lipid profile, FBS, and BMI
issues, sabotaging thinking, introduces behavioral were significantly modified after applying 4 inter-
experiments, educates effective responses, intro- ventions (P<0.05).
duces a new approach to problem- solving, and The characteristics of the study subjects are
etc. This program comprised 12, 90- min sessions shown in Table 1.

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Iranian J Publ Health, Vol. 42, No.1, Jan 2013, pp. 86-95
Table1: General characteristics of study population (data are presented as mean ± SD)

Baseline Post treatment
LEARN CBT CT MCT LEARN CBT CT MCT P value
(n=13) (n=17) (n=17) (n=14) (n=13) (n=17) (n=17) (n=14)
BMI 31.10 29.20 30.23 31.86 27.96 26.62 27.69 29.53
<0.05
(kg/m2) ± 4.41 ± 2.61 ± 4.18 ± 4.35 ± 4.90 ± 2.87 ± 4.16 ± 3.71
LDL cho-
86.92 90.52 88.47 93.85 94.53 93.41 111 117.07
lesterol <0.05
±12.85 ±13.03 ±20.26 ±27. 66 ±25.95 ±15.57 ±17.28 ±34.26
(mg/dl)
HDL cho-
62.00 64.41 48.35 53.00 60.00 49.00 45.23 44.50
lesterol <0.05
±5.77 ±7.61 ±4.59 ±17.32 ±28.23 ±6.42 ±4.14 ±5.86
(mg/dl)
Cholesterol 172.31 179.94 184.12 195.36 169.38 162.76 159.24 170.64
<0.05
(mg/dl) ±16.93 ±20.73 ±17.36 ±41.91 ±23.04 ±22.87 ±23.98 ±31.06
TG (mg/dl) 115.46 120 122.76 140.64 85.46 95.52 116.29 117
<0.05
±20.27 ±32.88 ±26.14 ±43.49 ±19.73 ±26.80 ±32.76 ±31.34
FBS 74.69 77.64 75.76 79.35 80.84 78.11 85.88 87.71
<0.05
(mg/dl) ±5.64 ±4.28 ±4.03 ±5.49 ±5.01 ±5.87 ±4.49 ±7.41
BMI, Body mass index; LEARN, Lifestyle, Exercise, Attitude, Relationship, and Nutrition; CBT, Cogni-
tive-behavior therapy; CT, Cognitive therapy; MCT, Metacognitive therapy; FBS, Fast blood sugar; LDL,
Low dense lipid; HDL, High dense lipid; TG, Triglyceride

Furthermore, repeated measure design analysis
showed there were significant mean differences Conducting multiple comparisons with Scheffe
(P<0.05) between 4 groups in HDL cholesterol, test reflected that the HDL cholesterol concentra-
TG levels and FBS concentrations (Table 2). tions were significantly higher in LEARN group
in comparison to two other groups (i.e. CT and
Table 2: Comparison of BMI, FBS and lipid profile
MCT, P<0.05) (Table 3). Furthermore, HDL cho-
concentrations among four groups
lesterol varieties in CBT group was significantly

higher than CT group (P<0.05). FBS varieties
F Df1 Df2 P value were significantly higher among MCT group than
BMI (kg/m2) 1.361 3 55 0.246 two other groups (i.e. CBT and LEARN, P<0.05),
LDL cholesterol too. These changes are depicted in Fig. 1-2.
2.090 3 57 0.112
(mg/dl)
HDL cholesterol
7.441 3 57 0.0001
(mg/dl)
Cholesterol (mg/dl) 0.896 3 57 0.449
TG (mg/dl) 3.227 3 57 0.029
FBS (mg/dl) 8.444 3 57 0.0001
BMI, Body mass index; LEARN, Lifestyle, Exercise, Atti-
tude, Relationship, and Nutrition; CBT, Cognitive-behavior

therapy; CT, Cognitive therapy; MCT, Metacognitive thera-
py; FBS, Fast blood sugar; LDL, Low dense lipid; HDL,
High dense lipid; TG, Triglyceride

90 Available at: http://ijph.tums.ac.ir
Agahheris et al.: Lipid Profile Improvement after Four Group Psychological

Table 3: Multiple comparisons of HDL and FBS concentrations among four groups

Scheffe Test for Multiple Comparisons
Group(I) Group(J) MD (I-J) SE P value
LEARN CT 14.2059* 3.46380 0.002
HDL levels (dl/mg) LEARN MCT 12.2500* 3.62105 0.015
CBT CT 9.9118* 3.22463 0.032
MCT LEARN 5.7665* 1.38477 0.002
FBS levels (dl/mg)
MCT CBT 5.6534* 1.29754 0.001
LEARN, Lifestyle, Exercise, Attitude, Relationship, and Nutrition; CBT, Cognitive-behavior therapy; CT, Cognitive
therapy; MCT, Metacognitive therapy; FBS, Fast blood sugar; HDL, High dense lipid

Discussion

Nowadays applying multidisciplinary approaches
in overweight and obesity management are popu-
lar. These approaches encompass every aspect of
body weight and health, including nutrition, physi-
cal activity, behavior, cognitions and other factors
that may influence them. They focus on control-
ling environmental resources, social situations,

and daily lifestyle that deteriorate weight manage-

Fig.1: FBS concentration varieties had significant dif- ment attempts by obese and/ or overweight indi-
ferences in MCT group in comparison to the other viduals (e.g., unhealthy eating, sedentary activities,
groups (P<0.05)
sabotaging thinking patterns, dysfunctional behav-

iors, and etc.). Hence, it is expecting that combi-
nation of psychological interventions, nutritional
considerations, and physical activity guidelines
would be effective on modifying excess weight,
and adverse effects of overweight such as bad
blood lipids concentrations. Therefore, the objec-
tive of this research was to determine the effec-
tiveness of adding different psychological inter-
ventions to dietary plans on improving BMI and
the blood lipids concentrations.
Results revealed that all 4 interventions altered the
target variables in post treatment state in compari-
son to baseline. So that, BMI, HDL cholesterol,
total cholesterol and TG concentrations were re-
duced, but LDL cholesterol, and FBS levels were
increased in post treatment state. Williams (18)
believed that lack of healthy eating and exercise
Fig.2: HDL cholesterol concentration varieties are
habits together with ineffective ways of managing
significantly differed among LEARN and CBT in
stress increases blood lipid concentrations. So,
comparison to the other groups (P<0.05)
Available at: http://ijph.tums.ac.ir 91
Iranian J Publ Health, Vol. 42, No.1, Jan 2013, pp. 86-95
Weight loss programs that address all three above soothing the mental problems which could influ-
lifestyle factors may be an effective path to im- ence the physiological varieties by above pathway,
proving serum lipid profiles. Therefore, it tends too.
psychological interventions target healthy lifestyle In consistent with the results of some other stu-
would improve adherence to control and monitor dies (e.g. 41-44) another finding of this study was
food intake and physical activity in overweight that FBS concentrations were increased in all
individuals, and so result in BMI reduction, and groups especially among MCT group (because of
blood lipids concentrations improvement. Addi- using detached mindfulness techniques to relax
tionally, Taylor (22) proposed that there is a rela- mind and body) in comparison to the other two
tionship between emotions, beliefs, behavior, and groups (e.g. LEARN, and CBT). Although FBS
health outcomes (mind- body linkage), beliefs can varieties in pre- and post- test states are in normal
affect health outcomes through which affecting ranges (e.g. 70-115 mg/dl) it would be because of
decision- making about health- related behaviors body homeostasis reaction to reducing fat intake
and its options. In consistent with this study, and increasing complex carbohydrates intakes due
some researchers found that HDL concentrations to low fat diets ingredients. In addition to this,
significantly decrease during the weight reduction Keeping FBS concentrations in higher levels of
period of interventions but significantly increased normal range could delay physiological hunger,
when subjects were at a stabilized, reduced weight and so prevent binge eating.
(e.g. 11-13). Different studies have shown favora- The other finding was that CT and MCT had
ble improvements in blood lipid concentrations higher effects on reducing plasma HDL choles-
(i.e., reduced TG, and total cholesterol) with terol in comparison to LEARN program. This
weight loss as a result of decreased dietary fat in- finding reveals that CT and MCT can more readily
take and increased physical activity (12, 13, 38). addresses the practical problem and unique chal-
These findings are consistent with what were lenges (22) that clients with weight conditions face
found among research using aerobics alone or (15, 27), and facilitate compliant with diet plans or
plus restricting food intake (10-13, 18, 37, 38). activity exercise(15, 27) during weight loss phase.
Additionally, these findings could be explained by Moreover Werrij, Jansen, Mulkens, Elgersma,
unconscious pathway of mind-body linkage that Ament, and Hospers (41) have suggested that
considering emotional and physiological influence cognitive therapy has more enduring effects than
would affect the health outcomes, too. So, psy- pure behavioral treatments (such as LEARN).
chological interventions such as CBT would im- MCT which is one of CBT techniques aims to
prove the adaption with chronic conditions by change the way individuals experience and control
mediating behaviors and cognitions as the funda- thinking and the beliefs hold about cognition. So
mental core of treatment; Beck (39, 40) empha- this intervention tends to have more enduring ef-
sizes the way in which systematic errors in think- fects than pure behavioral treatments, too.
ing and unrealistic cognitive appraisal of events There are some potential limitations to the current
can lead to negative emotions and maladaptive study. First was the subjectivity of the self-report
behaviors. So, changing the mindset about dieting measures that were used to assess physical activity
and struggling to sabotage thoughts that dieters and dietary patterns. Another limitation was as the
have would improve weight loss and consequently sample was recruited of the general community
through body- mind pathway would alter positive- and females, results may not generalize to individ-
ly the serum lipid concentrations. Furthermore, uals seeking treatment in medical or community
Fisher and wells (21) proposed that challenging treatment settings or to overweight or obese males.
between metacognitive beliefs which are in the Despite these limitations the current study will
domains of thought- action fusion or thought- provide much needed information about benefits
object fusion, and beliefs about the need to react of applying multidisciplinary approaches in over-
to thoughts in special ways are important to weight and obesity management.
92 Available at: http://ijph.tums.ac.ir
Agahheris et al.: Lipid Profile Improvement after Four Group Psychological

Conclusion 5. Ogden CL, Carroll MD, Curtin LR,
McDowell MA, Tabak CJ, Flegal KM
Adding cognitive and metacognitive therapy to (2006). Prevalence of overweight and
the regular treatment of overweight and obesity obesity in the United States, 1999–2004.
would be a valuable step in facilitating and opti- JAMA, 295: 1549–55.
mizing treatments and attaining more beneficial 6. Mirzazadeh A, Sadeghirad B, Haghdoost
outcomes in the weight management area. AA, Bahrein F, Rezazadeh Kermani M
(2009).The Prevalence of Obesity in
Ethical considerations Iran in Recent Decade; a Systematic Re-
view and Meta-Analysis Study. Iranian J

Publ Health, 38, 3: 1-11.
Ethical issues (Including plagiarism, Informed
7. Global Health Risks (2009). GHH seminars
Consent, misconduct, data fabrication and/or fal-
Geneva, 17 November 2010. cited at:
sification, double publication and/or submission,
http://www.who.int/nutrition/en/in-
redundancy, etc) have been completely observed
dex.html .
by the authors.
8. Denke MA, Sempos CT, Grundy SM

(1993). Excess BW: An under recog-
Acknowledgments
nized contributor to high blood choles-

terol levels in white American men.
This research was supported by Behavior Science
Arch Intern Med, 153: 1093- 1103.
Research Center of Shahid Beheshti University of
9. Viroonudomphol D, Pongpaew P,
Medical Sciences. We are grateful to all the partici-
Tungtrongchitr R, Changbumrung S,
pants and staff who cooperated in this study. The
Tungtrongchitr A, Phonrat B, et al
authors declare that there is no conflict of inter-
(2003). The relationships between an-
ests.
thropometric measurements, serum vi-

tamin A and E concentrations and lipid
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