APPENDIX VIII. GLOSSARY OF TERMS

A | B | C | D | E | F | G | H | I | J | L | M | N | O | P | R | S | T | V | W | Y

Abdominal fat: Fat (adipose tissue) that is centrally distributed between the thorax and pelvis and that induces greater health risk.

Absolute risk: The observed or calculated probability of an event in a population under study, as contrasted with the relative risk.

Aerobic exercise: A type of physical activity that includes walking, jogging, running, and dancing. Aerobic training improves the efficiency of the aerobic energy-producing systems that can improve cardiorespiratory endurance.

Age-adjusted: Summary measures of rates of morbidity or mortality in a population using statistical procedures to remove the effect of age differences in populations that are being compared.  Age is probably the most important and the most common variable in determining the risk of morbidity and mortality.

Anorexiant: A drug, process, or event that leads to anorexia.

Anthropometric measurements: Measurements of human body height, weight, and size of component parts, including skinfold measurement. Used to study and compare the relative proportions under normal and abnormal conditions.

Atherogenic: Causing the formation of plaque in the lining of the arteries.

Behavior therapy: Behavior therapy constitutes those strategies, based on learning principles such as reinforcement, that provide tools for overcoming barriers to compliance with dietary therapy and/or increased physical activity.

Biliopancreatic diversion: A surgical procedure for weight loss that combines a modest amount of gastric restriction with intestinal malabsorption.

BMI: Body mass index; the body weight in kilograms divided by the height in meters squared (wt/ht²) used as a practical marker to assess obesity; often referred to as the Quetelet Index. An indicator of optimal weight for health and different from lean mass or percent body fat calculations because it only considers height and weight.

Body composition: The ratio of lean body mass (structural and functional elements in cells, body water, muscle, bone, heart, liver, kidneys, etc.) to body fat (essential and storage) mass. Essential fat is necessary for normal physiological functioning (e.g., nerve conduction). Storage fat constitutes the body's fat reserves, the part that people try to lose.

BRL 26830A: An atypical B adrenoreceptor agonist drug that in obese rodents showed an increased metabolic rate and caused a reduction in weight by decreasing body lipid content. It is not approved as a weight loss drug by FDA.

Carbohydrates: A nutrient that supplies 4 calories/gram. They may be simple or complex. Simple carbohydrates are called sugars, and complex carbohydrates are called starch and fiber (cellulose). An organic compound—containing carbon, hydrogen, and oxygen—that is formed by photosynthesis in plants. Carbohydrates are heat producing and are classified as monosaccharides, disaccharides, or polysaccharides.

Cardiovascular disease (CVD): Any abnormal condition characterized by dysfunction of the heart and blood vessels. CVD includes atherosclerosis (especially coronary heart disease, which can lead to heart attacks), cerebrovascular disease (e.g., stroke), and hypertension (high blood pressure).

Central fat distribution: The waist circumference is an index of body fat distribution. Increasing waist circumference is accompanied by increasing frequencies of overt type 2 diabetes, dyslipidemia, hypertension, coronary heart disease, stroke, and early mortality. In the body fat patterns called android type (apple shaped) fat is deposited around the waist and upper abdominal area and appears most often in men. Abdominal body fat is thought to be associated with a rapid mobilization of fatty acids rather than resulting from other fat depots, although it remains a point of contention. If abdominal fat is indeed more active than other fat depots, it would then provide a mechanism by which we could explain (in part) the increase in blood lipid and glucose levels. The latter have been clearly associated with an increased risk for cardiovascular disease, hypertension, and type 2 diabetes. The gynoid type (pear-shaped) of body fat is usually seen in women. The fat is deposited around the hips, thighs, and buttocks, and presumably is used as energy reserve during pregnancy and lactation.

Cholecystectomy: Surgical removal of the gallbladder and gallstones, if present.

Cholecystitis: Inflammation of the gallbladder, caused primarily by gallstones. Gallbladder disease occurs most often in obese women older than 40 years of age.

Cholesterol: A soft, waxy substance manufactured by the body and used in the production of hormones, bile acid, and vitamin D and present in all parts of the body, including the nervous system, muscle, skin, liver, intestines, and heart.  Blood cholesterol circulates in the bloodstream.  Dietary cholesterol is found in foods of animal origin.

Cimetidine: A weight loss drug that is thought to work by suppression of gastric acid or suppression of hunger by blocking histamine H2 receptors. It is not approved by the FDA.

Cognitive behavior therapy: A system of psychotherapy based on the premise that distorted or dysfunctional thinking, which influences a person's mood or behavior, is common to all psychosocial problems. The focus of therapy is to identify the distorted thinking and to replace it with more rational, adaptive thoughts and beliefs.

Cognitive rehearsal: A technique used in cognitive behavior therapy. In a weight loss program, for example, individuals first imagine the situation that is causing temptation (such as eating a high fat food), describe the thoughts and feelings that accompany the imagined situation, and make positive self-statements about the situation (e.g., "I am feeling good about choosing a low calorie drink rather than the high fat cheese.").  Then the next step is to follow the positive self-statement with an adaptive behavior (such as walking away from the buffet line to chat with a friend). Finally, individuals are encouraged to reward themselves for doing well in a difficult situation, with either positive statements or material rewards, or both. The idea is to rehearse one's thoughts and behaviors prior to experiencing the potentially difficult situation, and to be armed with healthy adaptive responses.

Cognitive restructuring: A method of identifying and replacing fear-promoting, irrational beliefs with more realistic and functional ones. 

Comorbidity: Two or more diseases or conditions existing together in an individual.

Computed tomography (CT) scans: A radiographic technique for direct visualization and quantification of fat that offers high image contrast and clear separation of fat from other soft tissues. CT can estimate total body adipose tissue volume and identify regional, subcutaneous, visceral, and other adipose tissue depots. Radiation exposure, expense, and unavailability restrict the epidemiologic use of CT.

Confounding: Extraneous variables resulting in outcome effects that obscure or exaggerate the "true" effect of an intervention.

Coronary heart disease (CHD): A type of heart disease caused by narrowing of the coronary arteries that feed the heart, which needs a constant supply of oxygen and nutrients carried by the blood in the coronary arteries. When the coronary arteries become narrowed or clogged by fat and cholesterol deposits and cannot supply enough blood to the heart, CHD results.

Cue avoidance: A stimulus control technique often used in weight loss programs in which individuals are asked to reduce their exposure to certain food cues by making a variety of changes in their habits. The rationale is to make it easier on oneself and reduce temptation by reducing contact with food cues. For example, coming home from work and feeling tired is a time when many people reach for the high fat foods if they are available. By not having the high fat foods within reach, one can avoid eating them.

Dexfenfluramine: A serotonin agonist drug used to treat obesity. FDA approval has been withdrawn.

Diabetes: A complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of relative or complete lack of insulin secretion by the beta cells of the pancreas or a result of defects of the insulin receptors.

Diastolic blood pressure: The minimum pressure that remains within the artery when the heart is at rest.

Diethylproprion: An appetite suppressant prescribed in the treatment of obesity.

Dopamine: A catecholamine neurotransmitter that is found primarily in the basal ganglia of the central nervous system. Major functions include the peripheral inhibition and excitation of certain muscles; cardiac excitation; and metabolic, endocrine and central nervous system actions.

Dual energy X-ray absortiometry (DEXA): A method used to estimate total body fat and percent of body fat. Potential disadvantages include whole body radiation and the long time required for scanning while the subject lies on a hard table.

Dyslipidemia: Disorders in the lipoprotein metabolism; classified as hypercholesterolemia, hypertriglyceridemia, combined hyperlipidemia, and low levels of high-density lipoprotein (HDL) cholesterol. All of the dyslipidemias can be primary or secondary. Both elevated levels of low-density lipoprotein (LDL) cholesterol and low levels of HDL cholesterol predispose to premature atherosclerosis.

Efficacy: The extent to which a specific intervention, procedure, regimen, or service produces a beneficial result under ideal conditions. Ideally, the determination of efficacy is based on the results of a randomized control trial.

Energy balance: Energy is the capacity of a body or a physical system for doing work. Energy balance is the state in which the total energy intake equals total energy needs.

Energy deficit: A state in which total energy intake is less than total energy need.

Ephedrine: A sympathomimetic drug that stimulates thermogenesis in laboratory animals and humans. Animal studies show that it may reduce fat content and, therefore, body weight by mechanisms that probably involve increased expenditure and reduced food intake.

Extreme obesity: A body mass index 40.

Femoxetine: A selective serotonin reuptake inhibitor drug used in obese patients for weight loss.

Fenfluramine: A serotonin agonist drug used in the treatment of obesity. FDA approval has been withdrawn.

Fibrinogen: A plasma protein that is converted into fibrin by thrombin in the presence of calcium ions. Fibrin is responsible for the semisolid character of a blood clot.

Fluoxetine: An antidepressant drug used to promote weight loss whose action is mediated by highly specific inhibition of serotonin reuptake into presynaptic neurons. Serotonin acts in the brain to alter feeding and satiety by decreasing carbohydrate intake, resulting in weight reduction.

Framingham Heart Study: Study begun in 1948 to identify constitutional, environmental, and behavioral influences on the development of cardiovascular disease. Framingham data show that increased relative weight and central obesity are associated with elevated levels of risk factors (e.g., cholesterol, blood pressure, blood glucose, uric acid), increased incidence of cardiovascular disease, and increased death rates for all causes combined.

Gallstones: Constituents in the gallbladder that are not reabsorbed, including bile salts and lipid substances such as cholesterol that become highly concentrated. They can cause severe pain (obstruction and cramps) as they move into the common bile duct. Risk factors for cholesterol gallstone formation include female gender, weight gain, overweight, high energy intake, ethnic factors (Pima Indians and Scandinavians), use of certain drugs (clofibrate, estrogens, and bile acid sequestrants), and presence of gastrointestinal disease. Gallstones sometimes develop during dieting for weight reduction. There is an increased risk for gallstones and acute gallbladder disease during severe caloric restriction.

Gastric banding: Surgery to limit the amount of food the stomach can hold by closing part of it off. A band made of special material is placed around the stomach near its upper end, creating a small pouch and a narrow passage into the larger remainder of the stomach. The small outlet delays the emptying of food from the pouch and causes a feeling of fullness.

Gastric bubble/balloon: A free-floating intragastric balloon used in the treatment of obesity.

Gastric bypass: A surgical procedure that combines the creation of small stomach pouches to restrict food intake and the construction of bypasses of the duodenum and other segments of the small intestine to cause food malabsorption. Patients generally lose two-thirds of their excess weight after 2 years.

Gastric exclusion:  Same as gastric partitioning and Roux-en Y bypass. A small stomach pouch is created by stapling or by vertical banding to restrict food intake. A Y-shaped section of the small intestine is attached to the pouch to allow food to bypass the duodenum as well as the first portion of the jejunum.

Gastric partitioning:  See gastric exclusion.

Gastroplasty: See also jejuno-ileostomy. A surgical procedure that limits the amount of food the stomach can hold by closing off part of the stomach. Food intake is restricted by creating a small pouch at the top of the stomach where the food enters from the esophagus. The pouch initially holds about 1 ounce of food and expands to 2-3 ounces with time. The pouch's lower outlet usually has a diameter of about 1/4 inch. The small outlet delays the emptying of food from the pouch and causes a feeling of fullness.

Genotype: The entire genetic makeup of an individual. The fundamental constitution of an organism in terms of its hereditary factors. A group of organisms in which each has the same hereditary characteristics.

Glucose tolerance: The power of the normal liver to absorb and store large quantities of glucose and the effectiveness of intestinal absorption of glucose. The glucose tolerance test is a metabolic test of carbohydrate tolerance that measures active insulin, a hepatic function based on the ability of the liver to absorb glucose. The test consists of ingesting 100 grams of glucose into a fasting stomach; blood sugar should return to normal in 2 to 21 hours after ingestion.

Hemoglobin : One of the fractions of glycosylated hemoglobin A1c. Glycosylated hemoglobin is formed when linkages of glucose and related monosaccharides bind to hemoglobin A and its concentration represents the average blood glucose level over the previous several weeks. HbA1c levels are used as a measure of long-term control of plasma glucose (normal, 4 to 6 percent). In controlled diabetes mellitus, the concentration of glycosylated hemoglobin A is within the normal range, but in uncontrolled cases the level may be 3 to 4 times the normal conentration.  Generally, complications are substantially lower among patients with Hb levels of 7 percent or less than in patients with HbA1c levels of 9 percent or more.

Hemorrhagic stroke: A disorder involving bleeding within ischemic brain tissue. Hemorrhagic stroke occurs when blood vessels that are damaged or dead from lack of blood supply (infarcted), located within an area of infarcted brain tissue, rupture and transform an "ischemic" stroke into a hemorrhagic stroke. Ischemia is inadequate tissue oxygenation caused by reduced blood flow; infarction is tissue death resulting from ischemia. Bleeding irritates the brain tissues, causing swelling (cerebral edema). Blood collects into a mass (hematoma). Both swelling and hematoma will compress and displace brain tissue.

Heritability: The proportion of observed variation in a particular trait that can be attributed to inherited genetic factors in contrast to environmental ones.

High-density lipoproteins (HDL): Lipoproteins that contain a small amount of cholesterol and carry cholesterol away from body cells and tissues to the liver for excretion from the body. Low-level HDL increases the risk of heart disease, so the higher the HDL level, the better. The HDL component normally contains 20 to 30 percent of total cholesterol, and HDL levels are inversely correlated with coronary heart disease risk.

Hirsutism: Presence of excessive body and facial hair, especially in women; may be present in normal adults as an expression of an ethnic characteristic or may develop in children or adults as the result of an endocrine disorder. Apert's hirsutism is caused by a virilizing disorder of adrenocortical origin. Constitutional hirsutism is mild-to-moderate hirsutism present in individuals exhibiting otherwise normal endocrine and reproductive functions; it appears to be an inheritable form of hirsutism and commonly is an expression of an ethnic characteristic.  Idiopathic hirsutism is of uncertain origin in women, who may exhibit menstrual abnormalities and sterility. Some authorities believe the hirsutism reflects hypersecretion of adrenocortical androgens.

Hypercholesterolemia (high blood cholesterol):  Cholesterol is the most abundant steroid in animal tissues, especially in bile and gallstones. The relationship between the intake of cholesterol and its manufacture by the body to its utilization, sequestration, or excretion from the body is called the cholesterol balance. When cholesterol accumulates, the balance is positive; when it declines, the balance is negative. In 1993, the NHLBI National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults issued an updated set of recommendations for monitoring and treatment of blood cholesterol levels. The NCEP guidelines recommended that total cholesterol levels and subfractions of high-density lipoprotein (HDL) cholesterol be measured beginning at age 20 in all adults, with subsequent periodic screenings as needed. Even in the group of patients at lowest risk for coronary heart disease (total cholesterol 200 mg/dL and HDL 35 mg/dL), the NCEP recommended that rescreening take place at least once every 5 years or upon physical examination.

Hypertension: High blood pressure (i.e., abnormally high blood pressure tension involving systolic and/or diastolic levels). The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure defines hypertension as a systolic blood pressure of 140 mm Hg or greater, a diastolic blood pressure of 90 mm Hg or greater, or taking hypertensive medication. The cause may be adrenal, benign, essential, Goldblatt's, idiopathic, malignant PATE, portal, postpartum, primary, pulmonary, renal or renovascular.

Hypertriglyceridemia: An excess of triglycerides in the blood that is an autosomal dominant disorder with the phenotype of hyperlipoproteinemia, type IV. The National Cholesterol Education Program defines a high level of triglycerides as being between 400 and 1,000 mg/dL.

Incidence: The rate at which a certain event occurs (i.e., the number of new cases of a specific disease occurring during a certain period).

Insulin-dependent diabetes mellitus (type I diabetes): A disease characterized by high levels of blood glucose resulting from defects in insulin secretion, insulin action, or both. Autoimmune, genetic, and environmental factors are involved in the development of type I diabetes.

Ischemic stroke: A condition in which the blood supply to part of the brain is cut off. Also called "plug-type" strokes. Blocked arteries starve areas of the brain controlling sight, speech, sensation, and movement so that these functions are partially or completely lost. Ischemic stroke is the most common type of stroke, accounting for 80 percent of all strokes. Most ischemic strokes are caused by a blood clot called a thrombus, which blocks blood flow in the arteries feeding the brain, usually the carotid artery in the neck, the major vessel bringing blood to the brain. When it becomes blocked, the risk of stroke is very high.

Jejuno-ileostomy: See gastroplasty.

J-shaped relationship: The relationship between body weight and mortality.

Lipoprotein: Protein-coated packages that carry fat and cholesterol throughout the bloodstream.  There are four general classes: high-density, low-density, very low-density, and chylomicrons.

Locus/loci: A general anatomical term for a site in the body or the position of a gene on a chromosome.

Longitudinal study: Also referred to as a "cohort study" or "prospective study"; the analytic method of epidemiologic study in which subsets of a defined population can be identified who are, have been, or in the future may be exposed or not exposed, or exposed in different degrees, to a factor or factors hypothesized to influence the probability of occurrence of a given disease or other outcome. The main feature of this type of study is to observe large numbers of subjects over an extended time, with comparisons of  incidence rates in groups that differ in exposure levels.

Low-calorie diet (LCD): Caloric restriction of about 800 to 1,500 calories (approximately 12 to 15 kcal/kg of body weight) per day.

Low-density lipoprotein (LDL): Lipoprotein that contains most of the cholesterol in the blood.  LDL carries cholesterol to the tissues of the body, including the arteries. A high level of LDL increases the risk of heart disease. LDL typically contains 60 to 70 percent of the total serum cholesterol and both are directly correlated with CHD risk.

Lower-fat diet: An eating plan in which 30 percent or less of the day's total calories are from fat.

Macronutrients: Nutrients in the diet that are the key sources of energy, namely protein, fat, and carbohydrates.

Magnetic resonance imaging (MRI): Magnetic resonance imaging uses radio frequency waves to provide direct visualization and quantification of fat. The sharp image contrast of MRI allows clear separation of adipose tissue from surrounding nonlipid structures. Essentially the same information provided by CT is available from MRI, including total body and regional adipose tissue, subcutaneous adipose, and estimates of various visceral adipose tissue components. The advantage of MRI is its lack of ionizing radiation and hence its presumed safety in children, younger adults, and pregnant women. The minimal present use of MRI can be attributed to the expense, limited access to instrumentation, and long scanning time.

Menopause: The cessation of menstruation in the human female, which begins at about the age of 50.

Meta-analysis: Process of using statistical methods to combine the results of different studies. A frequent application is pooling the results from a set of randomized controlled trials, none of which alone is powerful enough to demonstrate statistical significance.

Mianserine: An antidepressant sometimes used in the pharmacotherapy of bulimia nervosa.

Midaxillary line: An imaginary vertical line that passes midway between the anterior and posterior axillary (armpit) folds.

Monounsaturated fat: An unsaturated fat that is found primarily in plant foods, including olive and canola oils.

Myocardial infarction (MI): Gross necrosis of the myocardium as a result of interruption of the blood supply to the area; it is almost always caused by atherosclerosis of the coronary arteries, upon which coronary thrombosis is usually superimposed.

NHANES: National Health and Nutrition Examination Survey; conducted every 10 years by the National Center for Health Statistics to survey the dietary habits and health of U.S. residents.

Neural tube defects: These defects include problems stemming from fetal development of the spinal cord, spine, brain, and skull, and include birth defects such as spina bifida, anencephaly, and encephalocele. Neural tube defects occur early in pregnancy at about 4 to 6 weeks, usually before a woman knows she is pregnant. Many babies with neural tube defects have difficulty walking and with bladder and bowel control.

Neuronal atrophy: Nerve cell death and functional loss.

Obesity: The condition of having an abnormally high proportion of body fat. Defined as a body mass index (BMI) of greater than or equal to 30. Subjects are generally classified as obese when body fat content exceeds 30 percent in women and 25 percent in men. The operational definition of obesity in this document is a BMI 30.

Observational study: An epidemiologic study that does not involve any intervention, experimental or otherwise. Such a study may be one in which nature is allowed to take its course, with changes in one characteristic being studied in relation to changes in other characteristics.  Analytical epidemiologic methods, such as case-control and cohort study designs, are properly called observational epidemiology because the investigator is observing without intervention other than to record, classify, count, and statistically analyze results.

Orlistat: A lipase inhibitor used for weight loss. Lipase is an enzyme found in the bowel that assists in lipid absorption by the body. Orlistat blocks this enzyme, reducing the amount of fat the body absorbs by about 30 percent. It is known colloquially as a "fat blocker." Because more oily fat is left in the bowel to be excreted, Orlistat can cause an oily anal leakage and fecal incontinence. Orlistat may not be suitable for people with bowel conditions such as irritable bowel syndrome or Crohn's disease.

Osteoarthritis: Noninflammatory degenerative joint disease occurring chiefly in older persons, characterized by degeneration of the articular cartilage, hypertrophy of bone at the margins, and changes in the synovial membrane. It is accompanied by pain and stiffness.

Overweight: An excess of body weight but not necessarily body fat; a body mass index of 25 to 29.9 kg/m².

Peripheral regions: Other regions of the body besides the abdominal region (i.e., the gluteal-femoral area).

Pharmacotherapy: A regimen of using appetite suppressant medications to manage obesity by decreasing appetite or increasing the feeling of satiety. These medications decrease appetite by increasing serotonin or catecholamine—two brain chemicals that affect mood and appetite.

Phenotype: The entire physical, biochemical, and physiological makeup of an individual as determined by his or her genes and by the environment in the broad sense.

Phentermine: An adrenergic isomeric with amphetamine, used as an anorexic; administered orally as a complex with an ion-exchange resin to produce a sustained action.

Polyunsaturated fat: An unsaturated fat found in greatest amounts in foods derived from plants, including safflower, sunflower, corn, and soybean oils.

Postprandial plasma blood glucose: Glucose tolerance test performed after ingesting food.

Prevalence: The number of events, e.g., instances of a given disease or other condition, in a given population at a designated time. When used without qualification, the term usually refers to the situation at specific point in time (point prevalence). Prevalence is a number, not a rate.

Prospective study: An epidemiologic study in which a group of individuals (a cohort), all free of a particular disease and varying in their exposure to a possible risk factor, is followed over a specific amount of time to determine the incidence rates of the disease in the exposed and unexposed groups.

Protein: A class of compounds composed of linked amino acids that contain carbon, hydrogen, nitrogen, oxygen, and sometimes other atoms in specific configurations.

Randomization: Also called random allocation. Is allocation of individuals to groups, e.g., for experimental and control regimens, by chance. Within the limits of chance variation, random allocation should make the control and experimental groups similar at the start of an investigation and ensure that personal judgment and prejudices of the investigator do not influence allocation. 

Randomized clinical trial (RCT): An epidemiologic experiment in which subjects in a population are randomly allocated into groups, usually called study and control groups, to receive or not to receive an experimental prevention or therapeutic product, maneuver, or intervention.  The results are assessed by rigorous comparison of rates of disease, death recovery, or other appropriate outcome in the study and control groups, respectively. RCTs are generally regarded as the most scientifically rigorous method of hypothesis testing available in epidemiology.

Recessive gene: A gene that is phenotypically expressed only when homozygous.

Refractory obesity: Obesity that is resistant to treatment.

Relative risk: The ratio of the incidence rate of a disease among individuals exposed to a specific risk factor to the incidence rate among unexposed individuals; synonymous with risk ratio. Alternatively, the ratio of the cumulative incidence rate in the exposed to the cumulative incidence rate in the unexposed (cumulative incidence ratio). The term relative risk has also been used synonymously with odds ratio. This is because the odds ratio and relative risk approach each other if the disease is rare ( 5 percent of population) and the number of subjects is large.

Resting metabolic rate (RMR): RMR accounts for 65 to 75 percent of daily energy expenditure and represents the minimum energy needed to maintain all physiological cell functions in the resting state. The principal determinant of RMR is lean body mass (LBM). Obese subjects have a higher RMR in absolute terms than lean individuals, an equivalent RMR when corrected for LBM and per unit surface area, and a lower RMR when expressed per kilogram of body weight. Obese persons require more energy for any given activity because of a larger mass, but they tend to be more sedentary than lean subjects.

Risk: The probability that an event will occur. Also, a nontechnical term encompassing a variety of measures of the probability of a generally unfavorable outcome.

Roux-en-Y bypass: See gastric exclusion; the most common gastric bypass procedure.

Saturated fat: A type of fat found in greatest amounts in foods from animals, such as fatty cuts of meat, poultry with the skin, whole-milk dairy products, lard, and in some vegetable oils, including coconut, palm kernel, and palm oils.  Saturated fat raises blood cholesterol more than anything else eaten. On a Step I Diet, no more than 8 to 10 percent of total calories should come from saturated fat, and in the Step II Diet, less than 7 percent of the day's total calories should come from saturated fat.

Secular trends: A relatively long-term trend in a community or country.

Serotonin: A monoamine vasoconstrictor, found in various animals from coelenterates to vertebrates, in bacteria, and in many plants. In humans, it is synthesized in the intestinal chromaffin cells or in the central or peripheral neurons and is found in high concentrations in many body tissues, including the intestinal mucosa, pineal body, and central nervous system.  Produced enzymatically from tryptophan by hydroxylation and decarboxylation, serotonin has many physiologic properties (e.g., inhibits gastric secretion, stimulates smooth muscle, serves as central neurotransmitter, and is a precursor of melatonin).

Sibutramine: A drug used for the management of obesity that helps reduce food intake and is indicated for weight loss and maintenance of weight loss when used in conjunction with a reduced-calorie diet. It works to suppress the appetite primarily by inhibiting the reuptake of the neurotransmitters norepinephrine and serotonin.  Side effects include dry mouth, headache, constipation, insomnia, and a slight increase in average blood pressure. In some patients it causes a higher blood pressure increase.

Sleep apnea: A serious, potentially life-threatening breathing disorder characterized by repeated cessation of breathing due to either collapse of the upper airway during sleep or absence of respiratory effort.

Social pressure: A strategy used in behavior therapy in which individuals are told that they possess the basic self-control ability to lose weight, but that coming to group meetings will strengthen their abilities. The group is asked to listen and give advice, similar to the way many self-help groups, based on social support, operate.

Stoma size: The size of a new opening created surgically between two body structures.

Stress incontinence: An involuntary loss of urine that occurs at the same time that internal abdominal pressure is increased, such as with laughing, sneezing, coughing, or physical activity.

Stress management: A set of techniques used to help an individual cope more effectively with difficult situations in order to feel better emotionally, improve behavioral skills, and often to enhance feelings of control. Stress management may include relaxation exercises, assertiveness training, cognitive restructuring, time management, and social support. It can be delivered either on a one-to-one basis or in a group format.

Stroke: Sudden loss of function of part of the brain because of loss of blood flow. Stroke may be caused by a clot (thrombosis) or rupture (hemorrhage) of a blood vessel to the brain.

Submaximal heart rate test: Used to determine the systematic use of physical activity. The submaximal work levels allow work to be increased in small increments until cardiac manifestations such as angina pain appear. This provides a more precise manipulation of workload and gives a reliable and quantitative index of a person's functional impairment if heart disease is detected.

Surgical procedures: See jejuno-ileostomy, gastroplasty, gastric bypass, gastric partitioning, gastric exclusion, Roux-en Y bypass and gastric bubble.

Systolic blood pressure: The maximum pressure in the artery produced as the heart contracts and blood begins to flow.

Triglyceride: A lipid carried through the blood stream to tissues. Most of the body's fat tissue is in the form of triglycerides, stored for use as energy. Triglycerides are obtained primarily from fat in foods.

Type 2 diabetes: Usually characterized by a gradual onset with minimal or no symptoms of metabolic disturbance and no requirement for exogenous insulin. The peak age of onset is 50 to 60 years. Obesity and possibly a genetic factor are usually present.

Validity: The degree to which the inferences drawn from study results, especially generalization extending beyond the study sample, are warranted when account is taken of the study methods, the representativeness of the study sample, and the nature of the population from which it is drawn.

Vertical banded gastroplasty: A surgical treatment for extreme obesity; an operation on the stomach that involves constructing a small pouch in the stomach that empties through a narrow opening into the distal stomach and duodenum.

Very low-calorie diet (VLCD): The VLCD of 800 (approximately 6-10 kcal/kg body weight) or fewer calories per day is conducted under physician supervision and monitoring and is restricted to severely obese persons. 

Very low-density lipoprotein (VLDL): The lipoprotein particles that initially leave the liver, carrying cholesterol and lipid. VLDLs contain 10 to 15 percent of the total serum cholesterol along with most of the triglycerides in the fasting serum; VLDLs are precursors of LDL, and some forms of VLDL, particularly VLDL remnants, appear to be atherogenic.

Visceral fat: One of the three compartments of abdominal fat. Retroperitoneal and subcutaneous are the other two compartments.

VO2 max: Maximal oxygen uptake is known as VO2 max and is the maximal capacity for oxygen consumption by the body during maximal exertion.  It is used as an indicator of cardiorespiratory fitness.

Waist circumference: To define the level at which the waist circumference is measured, a bony landmark is first located and marked. The subject stands, and the technician, positioned to the right of the subject, palpates the upper hip bone to locate the right ileum. Just above the uppermost lateral border of the right ileum, a horizontal mark is drawn and then crossed with a vertical mark on the midaxillary line. The measuring tape is then placed around the trunk, at the level of the mark on the right side, making sure that it is on a level horizontal plane on all sides. The tape is then tightened slightly without compressing the skin and underlying subcutaneous tissues. The measure is recorded in centimeters to the nearest millimeter.

Waist-hip-ratio (WHR): The ratio of a person's waist circumference to hip circumference. WHR looks at the relationship between the differences in the measurements of waist and hips. Most people store body fat in two distinct ways, often called the "apple" and "pear" shapes, either the middle (apple) or the hips (pear). For most people, carrying extra weight around their middle increases health risks more than carrying extra weight around their hips or thighs. Overall obesity, however, is still of greater risk than body fat storage locations or WHR. A WHR 1.0 is in the danger zone, with risks of heart disease and other ailments connected with being overweight.  For men, a ratio of .90 or less is considered safe, and for women, .80 or less.

Yohimbine: An alkaloid that possesses adrenergic-blocking properties and is used in arteriosclerosis and angina pectoris, formerly used as a local anesthetic and mydriatic and for its purported aphrodisiac properties.