Effect of the Healthy Dish Method to Reduce Waist Circumference in Teachers with Abdominal Obesity of a Peruvian University

Introduction

Obesity has been on the rise in recent decades, and has become a worldwide pandemic.¹ It is considered the most prevalent metabolic disease in the world, resulting in increased morbidity and risk of death.² About 30% of the world’s population is overweight and obese, a trend that is on the rise.³ In Mexico, 36% of adults are obese.⁴ In Peru, according to a report on non-transmissible and transmissible diseases, in 2019 the prevalence of obesity was 22.3%.⁵ In obesity, non-modifiable risk factors (RF) have been identified, such as genetic predisposition, and modifiable factors such as physical inactivity, poor eating habits, plus socioeconomic factors, which in a coordinated and interactive manner cause an imbalance between input and energy expenditure, which ceases to respond to body adjustments, triggering a significant long-term gain in fat mass and body weight.⁶

There are different anthropometric indicators to evaluate the presence of obesity, including body mass index (BMI), but it does not define whether it is lean mass or body fat.⁴ However, waist circumference, waist circumference/height ratio (WC/H) and waist/hip circumference (WC/H) are also measured.⁷

Waist circumference is a simple, very useful and inexpensive measure that has a close relationship with visceral fat and cardio-metabolic risk⁴ because visceral adipose tissue releases pro-inflammatory cytokines, tumor necrosis factor alpha (TNF-α), interleukin-6 (IL6) and less quantity of mediators with anti-inflammatory action such as adiponectin, which implies resistance to insulin, which plays an essential role in the pathogenesis of endothelial dysfunction and the appearance of atherosclerosis.⁷

During the COVID 19 pandemic, studies in hospitalized patients showed that those with abdominal obesity presented more severe courses and mortality, and that the levels of inflammatory markers correlated with visceral adiposity.^8–10

The best way to prevent chronic diseases is through a healthy eating plan. A few years ago, the nutritional pyramid was used, but it did not describe the proportions in which foods should be consumed. However, the Healthy Dish or Harvard Dish Method, which originated in 2011 at the Harvard School of Public Health by nutrition researchers, is currently very popular. It is useful, simple and illustrative so it is easy to understand, consisting of certain proportions of food on the dish represented by 50% of fruits and vegetables and the other half, 25% is protein and the other of carbohydrates preferring whole grains as several studies have shown that it is associated with a lower chance of obesity. Regarding fats, olive oil is suggested, avoiding partially hydrogenated fats. Dairy products should be consumed once or twice a day, sugar consumption should be reduced and water should be prioritized as a beverage, in addition to being physically active.^11,12

The American Diabetes Association (ADA) adapted the Harvard healthy dish method, which consists of dividing the dish into three sections with 50% vegetables, 25% protein and 25% carbohydrates.¹³

In recent decades, much importance has been given to community health as an approach in which strategies aimed at intervening in the health-disease process in specific communities must be implemented, the latter being the most important for the development, implementation and follow-up of the strategy used that considers the needs and participation of the community.¹⁴

In the nutritional counseling of the obese persons, it should be achieved that they modify certain eating and/or behavioral habits so that they become protagonists of their state of health.¹⁵

Therefore, the main objective of this research is to determine the effect of the healthy dish method to reduce waist circumference in teachers with abdominal obesity in a Peruvian university.

Materials and Methods

Type of Research: Applied

Research design: quasi-experimental, longitudinal and prospective.

Pre and post-test with two groups (experimental group and control group).

Independent variable: “Healthy dish” method (consisting of nutritional counseling).

Taking into account the model adapted by the American Diabetes Association (ADA), which is characterized by dividing the dish into three sections where 50% is vegetables, 25% protein and 25% carbohydrates (American Diabetes Association, 2020).

Cause X_____Y Effect

(Independent variable) (dependent variable)

Population: 61 teachers from the School of Psychology

Time: July to November 2023

Sample: 43 teachers

Type of sampling: non-probabilistic (by convenience)

Inclusion Criteria

• Teachers with abdominal obesity who gave their consent to participate.
• Those who had academic load in semester 2023- I.

Exclusion Criteria

• Those taking corticosteroids for a prolonged period of time due to chronic disease; pregnant women.

Collection of Information

Information was collected individually in a clinical history at the doctor’s office.

Data Collection Technique and Instrument

Observation by clinical examination; it was individual in a clinical history.

Instruments

Centimeter, Questionnaire, duly validated and reliable.

Conceptualization and Operationalization of Variables

Dependent variable: waist circumference.

Waist circumference: The measurement of the distance around the abdomen at the level of the navel used to diagnose abdominal obesity.

According to the Latin American Diabetes Association, abdominal obesity exists when the abdominal circumference is greater than or equal to 94 cm in men and greater than or equal to 88 cm in women.

Once the informed consent was signed, patients with abdominal obesity were identified by measuring waist circumference.

To measure waist circumference, a tape measure was used, taking into account its measurement at the midpoint between the lower costal border and the iliac crest at the level of the mid-axillary line, at the end of an expiration on 2 occasions and with the individual standing.

Of 46 participants with abdominal obesity who started the project, 3 withdrew, leaving 43 teachers. They were divided into two groups, control (21) and experimental (22), comparing both to see that there was no statistically significant difference between them.

Demographic data such as age, sex, marital status and other data from the medical record were collected through the clinical history.

The height in cm and weight in kg were also measured (scale and measuring rod) and the BMI will be obtained with the formula: Weight (Kg)/Height m² to evaluate nutritional status.

Underweight: less than 18.5 kg/m²

Normal weight: 18.5 to 24.9 kg/m²

Overweight: 25 to 29.9 kg/m²

Obesity Type I: 30–34.9 kg/m2; Type II: 35–39.9 kg/m2 and Type III: 40 or more kg/m²

The experimental group was given a two-session workshop, one online to deepen their knowledge of abdominal obesity and the other in person on the Healthy Dish Method, which was very didactic where the teachers demonstrated their know-how by building their own healthy dish, which they applied to their diet, with daily follow-up by the researchers.

For this purpose, the teachers were divided into 4 teams included in their respective WhatsApp group, each one led by a researcher who was in charge of collecting evidence of their daily meals through photos 5 days a week (Monday to Friday) for two months. After the first month, their waist circumference was measured and again after two months to evaluate the effect of the intervention.

Statistical Analysis

For the statistical analysis, descriptive statistics (statistical tables and graphs), inferential statistics (Student’s t-test for independent samples, as long as the data met the assumption of normality), and nonparametric statistics were used (Mann–Whitney U-test, if the assumption of normality was not met).

Table 1 shows that there was a predominance of patients between 40 and 49 years of age with abdominal obesity, representing 46.5%, of whom 34.8% were women. Table 2 shows that a larger number of teachers were married, representing 53.4%. Table 3 indicates the family pathological history of the teachers studied, 67.4% had a family history of hypertension, followed by cancer (60.4%), diabetes (53.3%), other diseases (28.8%), Thyroid disease (18.6%), Cardiopathy and Overweight or Obesity (11.1%). Table 4 shows that 62.7% of the participants were overweight followed by obesity in 30.2%. Table 5 shows that taking into account the patients with abdominal obesity according to waist circumference before and after the intervention, it was observed that before the application of the intervention, the experimental group was made up of 22 teachers with abdominal obesity and the control group of 21 teachers with the same characteristics. After the application of the healthy dish method, 40.9% of the teachers in the experimental group had reduced their waist circumference, but without normalizing it, while 23.8% of the control group had reduced their waist circumference. 54.5% of teachers in the experimental group normalized their waist circumference and 47.6% of the control group also normalized it. Only 4.54% of teachers in the experimental group had no change in their waist circumference, maintaining the same level as that obtained one month after the intervention, while in the control group, 19.0% did not change their waist circumference, and 9.52% of teachers in the control group increased their waist circumference. Therefore, there is a difference in the effect of the Healthy Dish method to reduce waist circumference in teachers with abdominal obesity. In the comparison of the probability obtained in the test with the significance level proposed, the significant of the test was 0.021 < 0.05, the research hypothesis is accepted.

Table 1 Patients with Abdominal Obesity According to Age Group and Sex

Table 2 Patients with Abdominal Obesity According to Marital Status

Table 3 Patients with Abdominal Obesity According to Family Pathological History

Table 4 Patients with Abdominal Obesity According to Nutritional Status by BMI

Table 5 Patients with Abdominal Obesity According to Waist Circumference Before and After the Intervention

Discussion

In the research on teachers with abdominal obesity, the predominance was in women between 40 and 49 years of age, coinciding with the study conducted by Pajuelo et al, where it was more frequent in women over 40 years old who resided on the coast in urban areas.¹⁶

Similar results were obtained by Hidalgo et al, in their research conducted in the State of Pernambuco, Brazil, with a prevalence of abdominal obesity in women of 80.7%.¹⁷

For their part, Menecier et al, carried out their study of adult women where 9 out of 10 women presented abdominal obesity.¹⁸

In their research, Aranceta et al, found a higher prevalence of abdominal obesity in females than in males, and that this also increases with age.¹⁹

Considering the marital status, there was a predominance of married people, coinciding with the research of Zapata et al, on the prevalence of overweight/obesity and abdominal obesity, which turned out to be higher in married women.²⁰ Similar results were presented by Teachman, where his married respondents tended to have more body weight than those who lived without a partner, since they performed social activities in union such as food consumption, physical exercise or sedentary lifestyle.²¹

Garcia and Viera found that abdominal obesity (AK) in women increased with age and being married or cohabiting.²²

Analyzing the family pathological history of the patients, a greater number of them had first- and second-degree relatives with arterial hypertension.

The hereditary history of arterial hypertension favors the risk of suffering from hypertensive disease, together with abdominal obesity, as evidenced by Araujo et al, in their study, whereby the risk of hypertension increased three times and they reported that 50.6% of the total population had a family history of arterial hypertension.²³

When calculating the body mass index (BMI), we found that most of the subjects were overweight, which is similar to the study by Pérez et al, where those identified as having abdominal obesity had a BMI of 25–29 kg/m².²⁴

Likewise, Hernandez et al concluded in their research that the participants were overweight and centrally obese.²⁵

When comparing the experimental and control groups, we observed that in both groups there was a decrease in waist circumference in most of the participants, since in the control group general recommendations were given regarding a low-calorie and low-fat diet. The experimental group decreased the abdominal perimeter to a greater extent after two months and a greater number of them even normalized it.

In a study conducted by Noriega, they applied nutritional counseling with the “Healthy Dish” Method to type 2 diabetic patients, which had a favorable effect on the reduction of weight, abdominal perimeter and BMI.²⁶

In a study carried out by Hassan, the participants who received the intervention with diet and exercise had a greater decrease in weight than the subjects in the control group, coinciding with our study.²⁷

Ortega et al, studied whether it was possible to stop having obesity (by normalizing the body mass index, abdominal perimeter and/or body fat percentage), showing that after 2 years, what was most normalized was the body fat percentage and thus the excess body fat; then the abdominal perimeter and thus abdominal obesity, and finally, the body mass index and thus general obesity.²⁸

Subero et al, evaluated the design of a healthy dish and the participants’ perceptions, concluding that the results were satisfactory and positively appreciated.²⁹

The limitation of this research is that since initially the teachers with abdominal obesity were not known, it was necessary to measure waist circumference to identify them, because not all subjects were likely to participate, so there is no randomization and the sample is smaller, not useful to generalize the results.

Conclusions

The healthy dish method has a positive effect on decreasing waist circumference in teachers with abdominal obesity and was statistically significant (0.021 < 0.05).

Recommendations

The “Healthy Dish” Method would be useful as a didactic strategy for health promotion and primary prevention activities in order to reduce the frequency of abdominal obesity in teachers and the rest of the population. In addition, educational intervention studies should be carried out with larger samples and in the counseling of patients in the work of healthcare professionals.

On the other hand, taking into account that the control group decreased waist circumference, although to a lesser extent, it shows that even if they are minimal changes being healthy, they also have a positive impact on the quality of life.