Exploring Literature Review and it Significance to Present Health and Social Care

Chapter One

Introduction

The aim of this assignment is to undertake a secondary research in exploring literature review and it significance to present health and social care. Clinical question will be formulated with rationale given for choice of topic by undertaking an extensive review of the literature. Following the systematic search, the student will critically evaluate literatures and other evidenced based information in order to discuss and answer the question. The design methods and data analysis will be discussed. It will also consider evidence based practice and the applications of research studies on nursing practice. Producing a dissertation that draws conclusion and makes recommendations for nursing practice will be deliberated.

Purpose Of Chapter

This chapter will introduce the background of the review, its rationale, research question, aims and objectives.

Background

The World Health Organisation (WHO, 20010) defines obesity as a complex condition, one with serious social and psychological manifestations that affects virtually any age and socioeconomic groups and threatens to overtake developed and developing countries. Obesity is the commonest form of malnutrition and is reacting epidemic proportions in developed and undeveloped countries around the world (Wadden et al. 2002). Arterburn et al. (2008) also defines obesity as a chronic condition characterised by an excess of body fat. It is often diagnosed in adults by using the Body Mass Index (BMI), which is calculated by measuring weight in kilograms and dividing this figure by height in metres squared (kg/ m?) ( Shepherd, 2009). Individuals with BMI ranging from 25Kg/m? indicate overweight whiles 30+ kgm? indicates obesity in adults. Overweight occurs when energy intake exceeds energy needs. Weight gain occurs when individuals for whatever reasons overeat or under exercise (Ahearne – Smith, 2008).

Obesity is a complex, costly and debilitating condition. The health implications of obesity are vast and the cost of treating this condition is a burden on the NHS, in terms of finance and resources. (Department of Health (DH) 2009a). Estimates put the cost of treating obesity and its associated complications at over one billion pounds per year in the UK, this figure is predicted to rise to ?45 billion by the year 2050 (Wintour, 2007). Research has estimated that in England, 6.8% of all deaths attributes to obesity (NHS, 2010). A recent study looking at data for 27 year period concluded that about one quarter of deaths in England was directly or indirectly related to obesity (Duncan et al. 2010). Predicted trends in obesity amongst men and women in England extrapolated to 2010 indicates that 26% of men and 28% of women will be clinically obese, imposing huge burden on the healthcare (National Audit Office, 2001).

Evidence indicates that there is a complex interrelationship between genetics, environment, childhood, family and non genetic factors (Kipping et al. 2008). There is also growing body of evidence that describes obesity as a polygenic disorder, with many genes being linked to or associated with a predisposition to adiposity (Batch and Baur, 2005). One of the latest genes to be associated with an increased risk of obesity is the fat, mass and obesity gene (Loos and Bouchard, 2008), which is thought to confer a predisposition to the disease through the control of food intake (Cecile et al 2008). Cairns and Stead (2009) discusses the increase in weight as a reflection of the trend in the western world generally and has been attributed to an abundance of food combined with disposition towards less physical activity of our daily lives. It further explains the diminished physical activity stems not only from changing employment patterns, but also from the many aids available to the average house holder, the ubiquitous motor car, and trends in the design of buildings and cities.

Obesity is a chronic metabolic disease, considered to be one of the main risk factors for cardiovascular disease and correlating with increased morbidity and mortality (NHS, 2010). Research shows that there is a link between excess body fat and the risk of developing a number of serious disease including diabetes, hypertension, cerebrovascular disease, arthritis and some cancers (Swain and Sacher, 2009). It has been confirmed that overweight individuals decreases their risk of premature death by doing physical activity even if their weight doesn’t change. People who are overweight can be limited in their ability to carry out physical activity because of reduced oxygen uptake capacity and painful muscles and joints. This limitations in locomotive power influences movement behaviour and lead to problems in activities of daily living.

Weight loss reduces blood pressure and improves metabolic profile. It also reduces the symptoms and improves several obesity related chronic conditions such as diabetes, obstructive sleep apnoea and osteoarthritis (SIGN, 2010). Weight loss is also associated with improvement of vascular morphology and function. Research by Pierce et al. (2008) demonstrated that short term, energy intake restricted weight loss alone is an effective intervention for improving endothelial function in obese subjects.

The impact of being overweight and obese has been studied from the perspective of health related quality of life (HRQL). Although, there is no standard definition of HRQL, It is generally accepted that it is subjective, multi dimensional assessment of the physical health, emotional wellbeing and psychosocial functioning (Hassan et al. 2003). There is also a growing body of cross – sectional data that support strong relationship between obesity and quality of life, in that quality of life tends to decrease as function of weight increase. Literature also supports that even small weight reduction leads to significant improvement in HRQL (Fontaine and Brofsky et al. 2001). Results of meta-analysis on the effects of randomised controlled trials of weight loss on HRQL using variety of intervention methods (behavioural, surgical, pharmacologic) suggest that the most consistent effects are found only when using obesity specific measures of HRQL (Masiejewski et al. 2005).

In addition, the majority of the studies in HRQL changes in obese and overweight individuals have focused on major medical techniques such as gastric bypass surgery and pharmacotherapy. Although these may be important strategies and options for obese individuals, the majority of populations are more likely to attempt behavioural programme focused on changing their dietary and exercise behaviours (Fontaine and Bartlett, 2001). There have been relatively few studies that have examined the effects of lifestyle modification programs on changes in quality life among overweight and obese individuals. Physical activity in combination with can be effective in improving health related quality of life in social functioning, mood and self esteem.

Many literatures exist on the effects of diet and exercise with no clear agreement on their long or short term efficacy. However, it is unclear if weight loss improves risk factors in all obese persons or only in high risk groups. Finally, it is important to determine if weight loss studies are applicable to everyday clinical management for these patients.

Aims and Objectives

The aim of the literature is to ascertain the long and short term effects of weight loss management programme (dietary, exercise and behavioural modification) on health related quality of life for patients with obesity problems.

To assess the clinical effectiveness and cost effectiveness of weight loss management.

To explore the long term effects of obesity treatment on body weight, risk factors for disease and quality of health and its benefits to the individual.

Research Question

The salient research question for the review is: ‘’Does structured weight reducing programme improve the quality of health for patients with obesity?. The weight reduction programme will focus on the non-pharmacological aspects of weight reduction programme which are diet, exercise and behavioural changes.

Rationale for Chosen Topic

The rationale for the choice of topic has been influenced by dominance in the media recently with regards to cost to the society in treating patients with obesity and co – morbidities associated with the condition. The role of the nurse involves educating and promoting the health of individual clients or patients in terms of weight management. The writer has also developed an interest in gaining knowledge and understanding of the conditions and interventions for promoting weight loss as some form of management in enhancing patient’s quality of life. Undertaking this research would add to the students knowledge and, hopefully to provide some answers to the research question.

Chapter Two

Methods

2.1 Purpose Of Chapter

This chapter will document the methods used to identify literature relating to the aims of the review. Also, how the literature search was conducted as well as the inclusion and exclusion criteria used in identifying relevant articles will be presented. Outcomes of the literature search and a presentation of the data will be included (Appendix 1).

2.2 Method

Partaking in evidence-based practice require the ability of nurses to evaluate and gather best available evidence, and integrate them into clinical practice and individual expertise (Burns and Grove, 2011). The fundamental purpose of literature review is to identify a broad spectrum of relevant information on a specific topic and develop a robust appraisal of its methodology and research designs to highlight any inconsistencies of the literature (Hewitt-Taylor, 2002). Many authors including Aveyard (2007) defines it as a systematic search and interpretation of a particular research area which adds to the implementation of evidence based protocols. Similarly, Hek et al (2002) explains it as a process of literature search and guiding of a topic to reveal ‘gaps’ in the current knowledge. Aveyard’s definition will be utilised for the purposes of this review as through systematic searches, relevant articles will be scrutinized for current knowledge and development of how healthcare professionals can effectively use evidence based in promoting the health of patients (Aveyard, 2007).

Some research studies may however have misleading findings due to their destitute research design, thus a critical appraisal tool would be used to critically appraise and disregard such evidence and provide findings from robust studies (Katrak, 2002). The appraisal tool chosen for the review was the Critical Appraisal Skills Programme Tool (CASP, Public Health Resource Unit, 2006). The CASP tool comprises a list of questions which enables the findings, study design and sample of research studies to be critically assessed and evaluated (Katrak et al, 2004). The CASP tool was chosen due to its simple guidance in critically appraising research studies while assessing its applicability and validity. Also both quantitative and qualitative research may be influenced by confounding variables, thus the CASP Tool helps to highlight variables that may reduce the validity of the results (Burns and Grove, 2011; Hurley et al, 2011).

Literature Search

Healthcare literature forms the basis of a great deal of work that nurses do, therefore searching and reviewing literature is a key skill as it helps to locate new initiative in its context and to examine new ideas (Steward, 2004). Literature search was used to device an evidence based question. Literature search is a structured approach to search information, producing the best available evidence for informing and guiding practice (Parahoo, 2006). Computers and electronic databases were used to undertake the literature search. This offered access to vast quantities of information, which could be retrieved more easily and quickly as compared to the manual search (Younger, 2004).

Data were gathered from literature search using the following databases, MEDLINE, COCHRANE, CINHAL, EMBASE, SYNERGY, OVID etc. Using specific electronic databases with the help of the librarian enabled the student to identify which databases were relevant to the topic or subject area. The selected database contained indexes of journal in the medical sciences, in addition to nursing, midwifery and related disciplines in retrieving a wider range of quality and relevant research to demonstrate wider reading and awareness of available databases. Some of the databases such as MEDLINE and COCHRANE library had some restrictions in accessing full text articles.

An initial search of the literature was used in narrowing down the process of topic selection. The following words were used for the search: obesity, overweight, training, exercise, physical activity, behaviour, adult, weight loss. This type of search highlighted many areas that could be exploited and conducted. Timmins and McCabe (2005) explains that using the initial search to identify a topic may gain an advantage over others because it gives certainty that there are recent and accessible published researched on a topic. Once the area of interest had been decided, a more focused and detailed search was used in incorporating many different sources. Burnard and Newell (2006) suggest that comprehensiveness and relevance are what reviewers needs to consider and adds that more specific the topic or question been search is, the more focused the results will be. Alternate key words with similar meanings such as bariatric patients, weight management were gleaned from databases and thesaurus to help elicit further information. Hek et al. (2002) states that the key principles for guiding literature search are being systematic, explicit, thorough and rigorous.

Boolean and truncating operators was also incorporated in searching for the literature by expanding, excluding or joining key words using ‘AND’ or ‘NOT’. These operators instruct the search engine to combine specific and necessary element within the last ten years (2001 – 2011) were utilised to enable the student to narrow and obtain the most recent articles relevant to the formulated question. The search was also extended to other countries because of limited articles in the UK and its applicability to the subject area. The inclusion criteria for the literature review are as follows: the study had to be researched articles, the subjects had to be adults, diet, exercise and behaviour modification had to be part of the treatment, the subjects would be overweight or obese. The inclusion and exclusion criteria also involved the first read of the articles that have been collected to get a sense of what they are about. Most of the published articles contained a summary or abstract at the beginning of the paper, which assisted with the process and enabling the decision as to whether it is worthy of further reading. Cohen (1990) framework for undertaking systematic review was adapted to aid with the process of narrowing and choosing the articles relevant for the research question proposed. This method involves the preview, question, read, summarise (PQRS) system kept the student focused and consistent but ultimately facilitated me with easy identification and retrieval of materials, leaving me with articles that were deemed relevant to the purpose of the review.

A total of 12 relevant articles were obtained after the literature search and with the application of the inclusion and exclusion criteria, only two articles were from the United Kingdom. The rest were from Australia, Holland, Netherlands, Canada and America. They all addressed the aims as well as the research question. All the articles were selected on the basis of its abstract, title, year and its relevance to research question. A summary of search history and findings of reviewed articles are presented in Appendix 1. Timmins and McCabe (2005) summary of grid table would be used to put the data extracted into chronological order and also into different classification can be seen in appendix 2. In order to be able to compare treatment outcomes from the different groups in the studies, the effect size will be used to analyse the studies intervention effect with reference to weight loss. In evaluating the literature, the systematic approach literature will be divided into classification and themes and presented chronologically.

Chapter Three

Analysis

3.1 Purpose of Chapter

This chapter explores the key findings of the selected research articles and provides a critical analysis of the research methodologies and findings. They will be presented as themes and will be compared and contrasted to reveal any ‘gaps’ or inconsistencies in the literature.

Findings

The aim of Jehn et al study was to examine the long-term effects on weight maintenance and dietary habits of participants in a clinical trial weight loss. Forty – four hypertensive overweight men and women were randomised in a comprehensive ‘lifestyle intervention’ group or monitoring group for 9 weeks. Participants in the ‘lifestyle intervention were fed hypo caloric version of the Dietary Attempts to stop Hypertension Diet (DASH) and also participated in a supervised moderate intensity exercise programme three times a week. The dash diet is rich in fruits, vegetables and low fats dairy products, and reduced in saturated fat, total fat and cholesterol. It has also been shown to substantially lower blood pressure in normotensive and hypertensive individuals (Appel et al 1997). Participants were provided all their meals. The monitoring group received no active intervention during the study but did receive up to three sessions of nutrition and lifestyle counselling following completion of data collection. One year following the completion of the DEW-IT trial, 44 participants were contacted for a single follow up visit. Participants were weighed on a certified balanced bean scale, and completed two brief dietary questionnaires in assessing reason for participating in the trial, changes in diet and exercise following participation and perceived barriers to maintaining weight loss. Wilcon test and t- test were used to compare groups for differences in continuous variables and chi square test were used to compare categorical variables. 42 of the original 44 participant returned for the 1 year follow up visit (n=23 for monitoring group and n=19 for the lifestyle group). The results showed weight loss at the completion of the study averaged 5.3kg in the lifestyle group and 0kg for the monitoring group. The intervention group in comparison to the monitoring group achieved significant improvements in their blood pressure and lipid profiles. Interestingly, 95% of the lifestyle intervention group and 52% of the monitoring group gained weight at the end of the study although, they both reported similar intakes of fruits and vegetables.

Leslee et al (2009) however conducted randomised clinical trial, using diet and exercise programme to reduce incontinence and to determine whether behavioural weight reduction intervention for overweight and obese women with incontinence would result in greater reductions in the frequency of incontinence episodes at 6 months as compared with control groups. 338 women were recruited between July 2004 and April 2006 in Alabama and Rhode Island. Women were eligible for the study if they were at least 30years of age, had body mass index of 25 – 50kgm? and at baseline reported 10 or more urinary incontinent episodes in a 7 day diary of voiding. The participants were required to monitor their food intake and physical activity for a week, to be able to walk unassisted for two blocks without stopping, and to agree not to initiate new treatment for incontinence and weight reduction for the duration of the study. Eligible participants were randomly assigned at a 2:1 ratio to an intensive 6 month behavioural weight loss programme or to a structured four session education programme (control group). Random assignments were concealed in tamper proof envelopes, the participants were aware of their treatment but the staff members who collected data were not. This helps to reduce the possibility of selection and study bias, thereby increasing the reliability and validity of the results (Polit and Beck, 2008). However, the cost and time pressures of undertaking RCTs compared with other research methodology may limit their feasibility or restrict recruitment. The participants completed questionnaires concerning their demographic characteristics, medical and behavioural history and history of incontinence. The subjects were weighed and height recorded. They were also trained to complete a 7day dairy of voiding. All participants were given a self-help behavioural treatment book with instructions for improving bladder control such as information about incontinence and pelvic floor exercises. Women assigned to the control group were scheduled to participate in four education sessions at months 1, 2, 3, 4. The participants in the weight loss group were provided with meal plans, encouraged to gradually increase physical activity. The results showed that the women in the intervention group had a mean weight loss of 8.0% (7.8kg) as compared with 1.6%(1.5kg) in the control group. After 6 months, the mean weakly number of incontinence episodes decreased by 47% in the intervention group, as compared with 28% in the control group. As compared with the control group, the intervention group had a greater decrease in the frequency of stress incontinence episodes (p=0.01), but not of urge incontinence episodes (p=0.14).

Obesity is associated with increased arterial stiffness, an early marker of vascular wall damage. However, data on the long-term vascular impact of intentional weight loss are limited. Goldberg et al (2008) aimed to evaluate the effect of weight loss induced by nutrition and exercise intervention on arterial compliance, metabolic and inflammatory parameters in obese patients who participated in a weight reduction programme. An open, prospective study, 37 obese subjects attended a 24weeks nutritional and exercise interventional programme. During the course, participants received diet instruction and participated in physical training once a week. Arterial elasticity was evaluated using pulse wave – contour analysis at baseline and end of study. Fasting glucose, HbA1C, insulin, lipid profile, hs-CRP, fibrinogen were measured. BMI Decreased from 36.1±7.4kgm? at baseline to 32.8±7.4kgm? after 6months. Large artery elasticity index increased from 12.1±4.1 to 15.8± 4.7ml/mmhg?10 during the study. Small artery elasticity index also showed an increase. There was significant improvement in fasting hyperglycaemia, HbA1C and significant decrease in LDL cholesterol, fibrinogen and C-reactive protein. Goldberg et al concluded that moderate weight loss induced by nutritional and exercise intervention improved small and large artery elasticity. The increase in arterial elasticity was associated with improvement in glucose and lipids homeostasis as well as markers of inflammation.

Obesity may affect lung function and so cause worsening of asthma. The mechanism by which weight loss can alleviate asthma may include alleviation of the airway collapse, stimulation of adrenal activity, and reduction in possible allergens, bronchoconstrictors or salt content in the diet (REF). Aarniala et al (2000) investigated the influence of weight reduction on obese patients with asthma. The design is an open study, two randomised parallel group in a private outpatient centre in Helsinki, Finland. Two groups of 19 obese patients with asthma (BMI=30-42kg?) recruited through newspaper advertisements. Base line measurements were taken and randomised to treatment group (19) or control group (19) by shuffling cards with the help of someone not involved in the study. The treatment group took part in a weight reduction programme included 12 group sessions, which lasted for 14wks, including 8weeks dieting period. The control group had sessions at the same intervals as the treatment group. All participants used normal medical care throughout the year. A peak flow metre and spirometer was used to measure their daily morning and evening pre bronchodilator and post bronchodilator peak expiratory flow, FVC, FEV as baseline, during the dieting period, at the end of dieting period, at 6months and 1yr. Data were analysed by means of start view 512+TM (brainpower) for apple Macintosh and SPSS. Mean weight reduction in the treatment group was 14.2kg of their pre-treatment, the control 0.3%. The corresponding figures after one year were 11.3% and weight gain of 2.2% for the treatment group. For the treatment group, health status improved with respect to all three subscales when compared with controls. By the end of weight reduction programme, reduction in dyspnoea in the treatment group was 13mm and 1mmin the control group. There were minimal exacerbations reported in the treatment group than in the control group. Aarniala et al concluded that weight reduction in obese patients with asthma improves lung function, symptoms, morbidity, and health status.

Similarly, Shawn et al (2004) prospectively studied 58 obese women with a body mass index of >30kgm?, 24 of whom had asthma, were enrolled in an intensive 6month weight loss programme to, whether loss of body mas would be correlated with improvements in bronchial reactivity, lung function, and disease specific health status. Patients were placed on a regime of three liquid meal replacement supplements per day, which delivered 300 kilocalories per meal. Those with severe obesity were enrolled into a long programme consisting of a diet of 900kcal per day that continued for twelve weeks. Patients were assessed in series of three paired study visits. Symptoms and disease specific quality of life were assessed using the St. George respiratory questionnaire (SGRQ) at baseline and every three months for duration of the study. The results showed that patients lost an average of 20kg over the 6 month period. For every 10% relative loss of weight the FVC improved by 92ml, and FEV1 improved by 73ml. However, bronchial reactivity did not significantly change with weight loss (p=0.23). Patients who lost > 13% of their pre-treatment weight experienced improvements in FEV, FVC and total lung capacity as compared to patients in the lower quartile who failed to loose significant amount of weight. Patient who completed the programme experienced improvements in respiratory health status.

Syed et al (2008) sought to identify the effect of weight reduction program on right and left ventricular structure and function. 62 patients presenting to the eating disorder clinic at a single academic institution for weight loss programs were prospectively enrolled. Subjects BMI were greater than 30mg/m? and attempting to lose weight by diet and exercise. Baseline and follow up transthoracic echocardiograms were obtained after at least 10% weight reduction or 6 months after baseline echocardiogram. Patient lost an average of 28±3kg over a period of 266±36days. Left ventricular mass index decreased significantly from 255.87±12 to 228±11gm. There were no statistically significant changes in contractility or diastolic indices. The ratios of early to late diastolic mitral inflow and annular velocities also increased. The results of the study concluded that weight reduction is associated with decreased in the ventricular diastolic size and left ventricular mass. However, the weight reduction did not associate statistically significant improvement in systolic or diastolic function.

Contrastingly, Kaukua et al (2003) studied health related quality of life in a clinically selected sample of obese patients. The study was carried at two obesity clinics at Helsinki University Central hospital. General occupational practitioners or hospital specialist referred all patients for weight loss treatment. Referral criteria included a body mass index ?35kgm?, failure of previous weight loss attempts, presence of obesity related comorbidity requiring weight loss and motivation to take part in a structured weight loss programme. An endocrinologist examined the patients and evaluated suitability for treatment. Patients were excluded if they had obesity due to secondary aetiology, had significant psychiatric disorders, severe eating disorders, and were eligible for bariatric surgery. The treatment comprised 10weeks on very low energy diets (VLED) and 17 weekly group visits with behavioural modification. The eight groups in this study were carried out during 1999 – 20000. The behaviour modification programme was on LEARN programme for weight control. The core elements of behaviour modification were goal setting, nutrition etc. Anthropometry assessments were used to measure the patient’s height, weight with calibrated electronic scale and calculated the BMI whiles the obesity specific questionnaires measured the obesity related psychosocial problems in everyday life. SPSS 10.0 was used to analyse all data. The Helsinki University central hospital and Peijas hospital ethical committies approved the study protocol and the informed consent form, which subjects sign after having received written and oral information. The results of the 126 patients who received treatment showed that the mean BMI did not differ from sexes. But the mean waist circumference was significantly larger in men. There was also decrease in obesity related psychosocial problems at the end of therapy and this improvement was maintained up to 2yrs despite weight regain. There was also large increase in physical functioning, improvement in body pain and general health, but not all the scale showed statistical significance relative to base line.

The study selection process outlined identified 8 studies. There was fair or good agreement for study inclusion suitability and data extraction. To summarise, all the eight research articles received ethical approval from the ethics committee to protect the rights, dignity and safety of the study participants. Consent was also gained from the subjects before participating in the research. They also had clear aims, methods, findings and conclusions.

Chapter 4

Discussion

4.1 Purpose Of Chapter

This chapter will give a detailed discussion of the prime findings highlighted whilst comparing and contrasting evidence. An interpretation of the themes will be made as well as evidence-based recommendations for future management, practice and education. The focal research question was: ‘’Does structured weight reducing programme improve the quality of health for patients with obesity

4.2 Discussion

This review has provided an alternative lens in understanding the importance of weight management and weight loss in improving the health of these patients as well as reducing it cost to the health service in managing this condition.

Weight reduction requires energy expenditure to exceed dietary energy intake. Despite a considerably amount of research dedicated to understandingthe role of diet in mediating weight control, there still remains disagreement regarding basic issues including the appropriate energy content, and perhaps more controversial, the ideal macronutrient distribution. Manipulation of the energy content will impact the rate of weight loss. Very low calorie diets will result in larger, more rapid reductions in weight loss, whereas a small to moderate reduction in energy intake will result in a small, steady rate of weight loss. The pertinent question becomes: does the rate of weight loss affect long term weight maintenance or other health related outcomes?

In most of the studies the subjects had lost significant amount of weight by the end of the intervention period. Some of the studies also indicated weight gain. There was significant weight loss in all groups. In Jehn et al (2006) study of weight loss intervention demonstrated the effectiveness of short term intensive programme of diet and exercise in blood pressure control. However, significant amount of weight gain occurred also in treatment group and consequently, weight at the 1 year follow visit did not differ between the treatment and control groups. Similar finding was also found in Kaukua et al single stranded 2 year follow up study of diet, exercise and behaviour modification for weight loss management. The patients in their study produced marked weight loss (12.5%) and wide range of improvements in health related quality of life in the short term. However, with longer follow after treatment, weight loss maintenance on average was only modest with mean regain of two thirds weight lost in 2yrs.Interestingly to weight loss, the improvements in health related quality of life started to diminish after 2 year. On average, only obesity related psychosocial problems and physical function showed improvements. Not only weight loss, but other factors such as therapeutic effects of taking part in a weight loss programme or increase in exercise and physical activity promoted by behavioural modification, might have been the cause of improved the quality of live as in the studies reviewed(reference).

Among overweight and obese women with urinary incontinence, the comprehensive weight loss programme in Leslee et al (2009) resulted in a significantly greater reduction in the frequency of self-reported urinary incontinence episodes as compared with the structured education programme. Higher proportion of women in the weight loss group than in the control group reported clinically meaningful reduction of at least 70% in the total weekly number of episodes of any incontinence, stress continence and urge incontinence. In addition the women in the weight loss group perceived greater improvements in their incontinence and were more satisfied with their improvements. These results suggest that overweight or obese women with stress, urge or mixed incontinence may benefit from weight loss. It has been hypothesized that obesity may contribute to urinary incontinence because of the increase in intraabdominal pressure due to central adiposity, which in turn increases bladder pressure and urethral mobility, exacerbating stress incontinence and possibly urge incontinence (Stewart, 2010). Weight reduction may reduce forces on the bladder and pelvic floor, thus reducing incontinence as a result from changes in dietary intake and physical activity (Subak et al. 20005).

Obesity is not only disproportionate gain of weight, rather it is a complex metabolic process associated with hypervolumic state, elevated pressures and dyslipidaemia. It is also associated with elevated cardiac output mainly produced by high stroke volume. Elevated stroke volume along with an expanded total blood volume presents an elevated preload to the left ventricle (reference). In Syed et al (2008) study, significant weight loss of 28.29±3kg was associated with decreased left ventricular mass, wall thickness, and diastolic dimensions. The beneficial changes were accompanied by preserved left ventricular systolic function. Contrary to the expectation, the observed decline in left ventricular wall thickness, and left ventricular mass did not translate into improved diastolic function or significant reduction in left atrial size. Instead, they observed increased early transmitral inflow velocities and decreased diastolic myocardial relaxation velocities. Left atrial dimensions decreased, but this does not reach statistical significance which represents that there is no decline in the size of left atrium. In Syed at al study, none of the findings are associated with improved diastolic function. This may represent that ventricular stiffening that leads to diastolic dysfunction associated with obesity may be less reversible than the other parameters. An explanation given to the lack of improvement in diastolic function is perhaps due to the short duration of the study or inadequate number of patients in the study. A larger study of longer duration will be neededto verify the myocardial mechanical abnormalities suggested by their study.

In contrast to Syed et al study, Goldberg et al (2008) study moderate weight loss induced by nutritional and exercise intervention was associated with improved small and large artery elasticity. The increase in elasticity was associated with improved glucose homeostasis and lipid profiles together with a reduction in the markers of inflammation. In response to a mean weight loss of 8% observed during 6month follow up, both small and large arterial elasticity increased significantly. Moreover, subjects who lost >10% of baseline body weight had significantly greater large arterial elasticity values and lower insulin resistancecompared to patients who did not lose or lost <5% of baseline body weight. In obesity, arterial stiffening is consistently observed in across all age groups and may contribute in part to excess cardiovascular morbidity and mortality. These harmful vascular effects may be mediated by comorbidities linked to obesity such as hypertension, dyslipidaemia, insulin resistance and diabetes. Recently, it has been demonstrated that excess body fat, abdominal visceral fat, and larger waist circumference have been associated with accelerated stiffening independent of blood pressure levels, ethnicity and age (Sutton-Tyrrell et al 2001). These results emphasize the adverse effects of obesity on the arterial wall and suggest that this effect is reversible with weight reduction.

Aarniala et al (2000) trial showed that in obese people with asthma, losing weight can improve asthma in terms of lung function, symptoms and health status. Several possible explanations exist for this improvement in asthma during and after weight reduction. In asthma airway obstruction causes early airway closure during expiration. This feature is accentuated by overweight. Weight reduction reduces closing capacity and exercise load which may alleviate asthma symptoms during exercise (reference). Although, general symptoms and lung function improved in the treatment group, use of rescued medication remained unchanged. This may reflect the fact that, whereas overall clinical picture of the asthma was improved by weight reduction, airway hyperactivity persisted.

Some strengths of the review were the use of randomised trials which can increase the reliability of the results, allowing the researchers to compare changes in weight between the intervention group and the control group that did not receive an intervention. Additionally, the researchers used actual weight rather than self-reported weight which has been shown to be unreliable for reporting long-term weight maintenance. Furthermore, participation for the follow up was good. This minimises the potential bias that those who volunteered to participate were more likely to have been successful at weight maintenance (Jehn,2006). The studies also indicate that without on-going contact, structural support and reinforcement of health goals, individuals are unable to maintain weight loss one year after intervention. Further research is needed to determine whether adding more intensive nutrition, education components and or cognitive behavioural therapy to dietary feeding trials can produce successful long-term weight maintenance.

In this review we included those three components that have been shown to be most important factors in weight loss; exercise, diet and behaviour modification. In view of the foregoing, the aims and research question of the review has been successfully answered and a wider understanding of the importance of weight management in helping to prevent morbidity and mortality of obesity. In addition to the findings, it also appears from the above that diet, exercise and behavioural modification has significant effects in managing weight loss and reducing obesity. Clinicians have to be skilled in eliciting and promoting the health of these individuals to prevent morbidity and mortality (ref)

4.3. Limitations

The main limitations of the studies are the small sample size, impeding the ability to examine predictors of weight change in multi variant analyses. A major limitation of this review was the use of researched articles from America, European countries as well as other Non – European countries such as Australia where the delivery of care differs from that of the United Kingdom and what may appear as important to American patients may not be important to that of the United Kingdom. Furthermore, the use of only published articles, poses the risk of publication bias as most journal articles do not deliberate on the ‘negative or no effect’ thus hidden evidence that is vital in synthesising the findings application of research question may be missed (Aveyard, 2007).

Limiting the exclusion and inclusion criteria from studies published from 2000 to 2011 meant that any valid research before that had to be excluded, thus any significant findings relevant to the review may have been overlooked (Jokinen et al, 2002). Although an attempt was made to retrieve recent data, literature into obesity and weight loss management commenced around the 1960’s thus it is a broad topic and not all relevant research studies could be included in the review (Verhallen et al, 2004). Lastly, financial restrictions were also a limitation of the review as most journals required membership or a fee to retrieve articles thus useful articles for the review may not have been attained.

4.4 Implications For Practice, Education, Managment And Future Rsearch

Adequate research has now been gathered to demonstrate diet, exercise and behaviour modification is important in the effective management of weight loss for patient with overweight or obesity problems. Eliciting the health concerns of these patients and the cost to both family and society in this review has demonstrated the urgent need to address the quality and effectiveness of the weight induced programme in improving the health of these patients in order to reduce the comorbidities associated with the condition.

The level of motivation in overweight individuals probably plays a very important role in the success or failure of weight treatment. Factors that influence motivation include the degree to which overweight individuals receive support from their families, advice and information from healthcare professional that can also set up realistic goals through continuous contact.

Conclusion

According to the present review, the treatment of overweight and obesity that promises the best results consist of diet, behaviour modification and exercise. Treatment with exercise alone cannot be expected to any significant weight loss, regardless of the type exercise. On the other hand, exercise can be important factor when it comes to preventing continued weight gain or maintaining lower weight even in the long-term. Thus this review reached an important conclusion that the treatment of overweight individuals requires a multidisciplinary approach. This approach means that representatives from all professions, dieticians, behavioural scientist, psychologist, psychotherapist, nurses, physical therapist and doctors must collaborate with each other