Impact of Lifestyle Intervention on the Estimated Visceral Fat Area and Skeletal Muscle Mass in Men with Obesity

Background: The lifestyle modification remains the fundamental approach for the obesity treatment. The aim of this study is to demonstrate the effect of the multimodal lifestyle intervention on the estimated visceral fat area versus changes in musculoskeletal mass in a cohort of adult men with obesity. Subjects and Methods: A retrospective cohort study in which the file of eigh-ty-two male subjects, aged 20 - 60 years, was studied for three months. Patients had been instructed to follow a balanced-hypocaloric diet, physical activity plan and general advice for combating the unhealthy lifestyle habits through the study period. Those who succeeded to loss > 5% of their body weight were classified as weight loser (WL) group, while others as weight resistant (WR) group. The results of In Body-720 bioelectric impedance analysis were used to report the fat mass (FM), visceral fat area (VFA), skeletal muscle mass (SMM), SMM/VFA ratio, osseous mass (OM), and basal metabolic rate (BMR) before and after the study period. Anthropometric meas-ures, glucose, and lipid profile were also analyzed. Paired t-test was used to detect the significance of change between before and after measures, independent sample t-test was used to compare WL vs. WR groups. Results: There were significant decreases in weight, FM (p < 0.05) and VFA (p < 0.001), in addition to a significant rise of SMM/VFA ratio (p


Introduction
The wide prevalence of obesity and its association with many preventable comorbidities makes the methods to combat that obesity is essential. Obesity-managing protocols may shift early to pharmacological or surgical solutions to obesity in order to achieve rapid general weight loss [1]. Although recent studies confirm that obesity-related comorbidities are primarily developed as a result of exaggeration and disturbance of the visceral adipose tissue which in turn produces dysregulation of many adipokines [2] [3]. Accordingly, the main problem of obesity is the exaggerated and dysregulated visceral adipose tissue. So, reduction of the visceral fat during weight loss therapy is the main target, not merely a loss of total body weight [4].
The integrative lifestyle modification which includes a balanced hypocaloric diet, stepped engagement in a regular physical activity plan [7], and the behavioral modification in a gradual model to acquire a healthier lifestyle is the cornerstone in obesity management [5] [6].
Bioelectrical impedance analysis (BIA) is a non-invasive technique that widely used in the clinical settings for body composition analysis. The impedance of the measured body is calculated by assessing the resistance and reactance of tissues in the presence of a circuit of multifrequency alternating current i.e. it electrically quantifies the tissues for diagnostic purposes [7]. A lot of parameters could be given by a BIA test such as fat mass (FM), visceral fat area (VFA), fat free mass, skeletal muscle mass (SMM), SMM/VFA ratio, osseous mass (OM) in addition to prediction of basal metabolic rate (BMR). It was reported that the BIA-estimated visceral fat area (eVFA) is highly related and close to that measured by computed tomography (CT) [8]. SMM/VFA ratio was proved to be the main factor in the relationship of the adipo-myokines such as iris in hormone to its metabolic functions [9] and to the development of metabolic syndrome [10].
Accordingly, the aim of this study is to demonstrate the effect of the multimodal lifestyle intervention on the estimated visceral fat area versus changes in musculoskeletal mass in a cohort of adult men with obesity.

Subjects and Methods
Subjects: All participants were cases of the weight reduction clinic, therapeutic nutrition clinical services in the college of applied medical sciences (CAMS), male sector, King Saud University, between September 2016 to January 2017.
Files of eighty-two adult individuals, 20 -62 years old were selected to be used in

Results
The mean age of participants of this study was 34. 25  Correlation of VFA with SMM ( Figure 1) showed a significant moderate correlation (r = 0.398, p = 0.010), while the OM failed to be significantly correlated with the VFA.
As shown in Table 1, before-after comparison of this cohort revealed highly  Table 2). Comparison of the demographic data between the two groups was presented in Table 3. Generally, weight resistance was common in low educational and socioeconomic status.

Discussion
Normalization of the lifestyle of patients with obesity or overweightedness by calorie-restricted and nutrients-complete diet, physical activity plan and acquisition of a healthier behavior, might improve the body composition and may provide a considerable method for management of obesity [13].
This report showed that intensive and integrated lifestyle modification which   fat mass loss and the eVFA loss. In another study, dietary interventions without properly planned physical activity resulted in losing more than 5 percent of body weight after six months of hypocaloric diet [14]. Furthermore, nutritional education especially healthy eating education resulted in improvement of dietary intake among a sample of university students [15]. Taken together, it became   clear that lifestyle interventions including diet, physical activity, and behavioral modification were much better than an individual modality of management.
This theory was supported by a recent study [16] that demonstrated the effect of the behavioral therapy alone as a non-diet lifestyle program for admitted morbid obesity patients with psychological comorbidity. It was concluded that morbidly obese participants might achieve a significant reduction in weight and amelioration of psychological manifestations. Additionally, the patient-physician rela- tionship plays an essential role in the management of obesity [17]. On another hand, a randomized controlled trial at the primary health care level [18] showed that a hypocaloric diet of proper macronutrient composition in a combination of physical activity practice had limited impact on body weight in adolescents. The different clinical setting may give explanation of this discrepancy.
Estimated VFA by using bioelectric impedance analysis was studied by many investigators [19]. One Japanese study stated that the cutoff value for estimated visceral fat area at 100 cm 2 is useful for diagnosis of cardiovascular risk factors associated with obesity [20]. This proved that lifestyle intervention could significantly reduce the VFA more than the total fat mass in addition to improvement of lipid panel among patients with obesity. This result was consistent with Nicklas et al., [21] who reported that weight loss among postmenopausal African-American and Caucasian women, caused by calorie restriction and practice of physical activities effectively reduce visceral fat area measured by computed tomography (CT). Considering the obesity degree, most of our cases were first-degree obesity and overweight (the mean basal BMI was 33.73 ± 5.76 kg/m 2 ). Thus, results of the current study could be considered as a continuation to a recent meta-analysis, which revealed that lifestyle modification trials including a physical activity could improve body weight and other cardiometabolic risk factors in the second and third degree of obesity [22].
In this study, cases were instructed to start low-intensity daily activities, and then gradually progress to a higher intensity. This pyramid-like progression in the intensity of the physical activity shared in the reduction of visceral adipose tissue. In contrary to this finding, Irving et al., [23] reported that only high-intensity exercise training could affect the visceral fat area among obese women. The gender difference may explain this discrepancy.
Furthermore, this intervention produced a partial improvement of lipid profile especially total cholesterol, LDL cholesterol, and triglycerides, while HDL insignificantly changed. Consistent with that, Unick et al., [24] stated that long-term intensive lifestyle intervention for severely obese patients produced a significant reduction in LDL, total cholesterol, triglycerides, glucose and blood pressure, but failed to produce favorable improvement of HDL cholesterol. On another hand, the results of the current study were not in line with the pediatric results of a multidisciplinary family-based lifestyle intervention which revealed insignificant effects on lipid profile. However, it significantly affects the adiposity, physical fitness and glucose homeostasis [25].
Despite of these positive results, this study has some limitations. The main limitations are the retrospective nature of this investigation and the use of BIA rather than the gold standard MRI.

Conclusion
In conclusion, the integrative multi-modality lifestyle intervention for obesity treatment might be a valuable method that reduces visceral fat area. Future re-

Conflicts of Interest
The author declares no conflicts of interest regarding the publication of this paper.