Intervention and Prevention

Obesity (2009) 17 6, 1178–1183. doi:10.1038/oby.2008.673

The Effect of Weight Loss on Sleep-disordered Breathing in Obese Teenagers

Stijn L. Verhulst¹, Hilde Franckx², Luc Van Gaal³, Wilfried De Backer⁴ and Kristine Desager¹

1. ¹Department of Pediatrics, University of Antwerp, Antwerp, Belgium
2. ²Zeepreventorium, De Haan, Belgium
3. ³Department of Endocrinology, Diabetology and Metabolism, University of Antwerp, Antwerp, Belgium
4. ⁴Department of Respiratory Medicine, University of Antwerp, Antwerp, Belgium

Correspondence: Stijn L. Verhulst (stijn.verhulst@ua.ac.be)

Received 16 July 2008; Accepted 25 December 2008; Published online 5 March 2009.

Abstract

The objective of this study was to assess the effect of weight loss on sleep-disordered breathing (SDB) in obese teenagers attending a residential treatment center. We also assessed whether the presence of SDB at the start of the weight management therapy was correlated with the amount of weight loss achieved. Obese teenagers were recruited and underwent anthropometry and sleep screening. Subjects with SDB (apnea hypopnea index (AHI)  2) received a follow-up screening after weight loss therapy. Sixty-one obese subjects were included (age = 14.8  2.3; BMI z score = 2.7  0.4). Thirty-one subjects were diagnosed with SDB with 38% continuing to have residual SDB after a median weight loss of 24.0 kg. Subjects with SDB had a higher median relative decrease in BMI z score compared to subjects without SDB which was 30.5, 33.6, and 50.4% in the group with AHI of the baseline screening study <> AHI <>5, respectively (P = 0.02). AHI of the baseline screening study correlated significantly with the relative decrease in BMI z score (partial r = 0.37; P = 0.003), controlling for gender, age, initial BMI z score, and time between both studies. In conclusion, weight loss was successful in treating SDB in obese teenagers. In addition, there was a positive association between the severity of SDB at the start of the treatment and the amount of weight loss achieved. These findings are in favor of considering weight loss as a first-line treatment for SDB in obese children and adolescents.

Introduction

The prevalence of childhood obesity is reaching epidemic proportions worldwide. One of the obesity-related complications that has received increasing attention in recent years is sleep-disordered breathing (SDB). Obese children have an increased prevalence of all types of SDB. For instance, the prevalence of obstructive sleep apnea syndrome is estimated at 13–59% (1,2,3,4,5,6). Recent reports also indicate that childhood obesity can be associated with central sleep apnea (6,7). Furthermore, SDB in overweight children and adolescents is independently associated with the metabolic syndrome and its components (8,9). Thus, SDB becomes a potential additional risk factor for the development of future cardiovascular morbidity. In this view, obese children with SDB should have specific treatment for SDB. Adenotonsillectomy is routinely performed as a first-line treatment for the obese child with SDB. However, adenotonsillectomy is only successful in approximately half of obese subjects with SDB (10,11). Furthermore, various studies have shown that obese children gain weight after upper airway surgery (11,12,13). This postoperative increase in BMI is probably one of the key factors responsible for the suboptimal effect of adenotonsillectomy (11). Therefore, and in light of the other obesity-related complications, it was proposed that weight loss should be the first-line treatment for SDB in childhood obesity (10). However, studies assessing the effect of weight loss on the severity of SDB in obese children and adolescents are scarce (14,15). The principal aims of this study were therefore to assess the effect of weight loss on the severity of SDB and to assess the effectiveness of weight loss quantitatively for SDB in obese children attending a residential treatment center. Furthermore, SDB can also be associated with changes in total day activity (13). This could hypothetically influence the results of the weight management program itself. The secondary aim of this study was therefore to investigate whether the severity of SDB at the start of the treatment influenced the amount of weight loss achieved.

Methods and Procedures

Study population

All obese children and adolescents of 10 years who were admitted at the revalidation center "Zeepreventorium" (De Haan, Belgium) were recruited between January 2007 and August 2007. Subjects followed a multicomponent treatment program consisting of moderate dietary restriction (1,400–1,600 kcal/day), regular physical activity, group and individual psychological support, and medical supervision (without antiobesity drugs). The diet during the residential program was based on conventional recommendations represented in the food pyramid (30% energy as fat, 15% energy as protein, and 55% energy as carbohydrates). It consisted of two servings of fruit, three servings of vegetables, 100 g of meat or 150 g of fish, skimmed milk and low-fat cheese, and high fiber staples. The patients received three meals and two snacks per day. All children received an individual physical training program for 4 h/week and performed various sports (2 h/week) and swimming (1 h/week). Extra physical activities were also performed within the children's age groups. The center provides swimming facilities and a great deal of leisure time is spent on outdoor group games. Before and after school, children were stimulated to exercise for 10 h/week or even more if they wanted to. All children had to be free of any acute disease at the moment of sleep screening and subjects with neuromuscular disease, laryngomalacia, and any genetic or craniofacial syndrome were excluded. This study was approved by the Ethical Committee of the University of Antwerp, and informed consent was obtained from the subjects and their parents.

Questionnaire and physical examination

A questionnaire regarding sleep disturbance, nighttime and daytime symptoms, and respiratory comorbidities was completed by the parents (16). This questionnaire was based on the Pediatric Sleep Questionnaire and on adult sleep questionnaires. The questionnaire also included the modified Epworth sleepiness scale for children (17). Habitual snoring was defined if the answer to the question "How often does your child snore?" is "often or always." All other questions could be answered by "yes" or "no." Tonsillar size was rated using the Brodsky scale (18). In view of a high prevalence of tonsillectomy, the scoring was modified as follows: (0) tonsillectomy; (1) tonsils are entirely within the tonsillar fossa; (2) tonsils occupy <25% src="http://www.nature.com/__chars/greater/special/ge/black/med/base/glyph.gif" alt="greater than or equal to" style="border-top-width: 0px; border-right-width: 0px; border-bottom-width: 0px; border-left-width: 0px; border-style: initial; border-color: initial; vertical-align: baseline; ">75% of the lateral dimension of the oropharynx.

Anthropometry

Height, weight, waist circumference, and waist-to-hip ratio were measured at the time of admission by skilled personnel, according to standardized techniques. Percentage body fat was measured by bioelectrical impedance analysis using the Wabitsch formula (19). BMI was calculated as weight in kilograms over height in meters squared, and was further analyzed as z scores (20). BMI z score reflects the number of standard deviations above or below the average value for a child's age and gender based on appropriate growth charts (20). The relative decrease in BMI z score (%) was defined as the difference between BMI z score after therapy and at baseline divided by the baseline BMI z score.

Sleep screening

All subjects underwent sleep screening as part of this research study, and this was performed using ApneaLink (ResMed, Switzerland). Respiratory airflow was measured by nasal pressure cannula, and blood oxygen saturation and pulse rate were recorded by pulse oxymeter and pulse sensor (sampling rate of 1 Hz). Apnea was defined as cessation of airflow lasting 2 breaths. Hypopnea was defined as 50% decrease in the amplitude of the airflow signal lasting 2 breaths with a concurrent desaturation of >3%. The apnea hypopnea index (AHI) was calculated as the sum of apneas and hypopneas divided by total recording time. All desaturations defined as decreases 4% from baseline oxygen saturation (SaO₂) were quantified (oxygen desaturation index, ODI). All recordings were manually reviewed and events associated with poor pulse tracings or during movement were excluded. For each child, mean SaO₂ (₂>), SaO₂nadir, and total duration of desaturation, expressed as percentage of total recording time with SaO₂ < src="http://www.nature.com/__chars/greater/special/ge/black/med/base/glyph.gif" alt="greater than or equal to" style="border-top-width: 0px; border-right-width: 0px; border-bottom-width: 0px; border-left-width: 0px; border-style: initial; border-color: initial; vertical-align: baseline; "> 2, further classified as mild (2 AHI < src="http://www.nature.com/__chars/greater/special/ge/black/med/base/glyph.gif" alt="greater than or equal to" style="border-top-width: 0px; border-right-width: 0px; border-bottom-width: 0px; border-left-width: 0px; border-style: initial; border-color: initial; vertical-align: baseline; "> 5) (21,22,23). 

Statistical analysis

Statistical analysis was performed with Statistica 7.0 (StatSoft, Tulsa, OK). From preliminary analysis combined with the reported results from Kalra et al. (15), 14 subjects would be needed to achieve statistical power in the SDB group (based on an initial AHI of 5.1  5 and an AHI of 1  1 after therapy; type I error rate of 5% and a power goal of 80%). The Shapiro-Wilk test was used to test normality. Normally distributed data were summarized as mean  s.d., skewed data as median and range. Comparisons between two groups were done with independent t test or Mann–Whitney U test. Comparisons between three groups were performed with one-way ANOVA with Tukey test as post hoc test or Jonckheere-Terpstra test as nonparametric alternative. Categorical variables were compared using ²-test or Fisher exact test when appropriate. Comparisons of variables before and after weight loss were done with Wilcoxon matched pairs test or with McNemar test. Correlations were computed using Pearson or Spearman correlation coefficient. Linear regression was used to investigate the association between the weight loss and the severity of SDB. Residual analyses were performed to check the validity of model assumptions. For all analyses, P <>

Results

Patient characteristics

This study included 61 obese children and adolescents with a mean age of 14.8 2.3 (range = 10.1–18.3). BMI averaged on 37.5  5.7 (range = 25.6–51.1) which corresponded to a mean z score of 2.7  0.4 (range = 1.9–3.7). Of 61 subjects, 19 were boys (31%). After 5.2  0.5 months of therapy, the median absolute decrease in BMI z score was 0.9 (range = 0.5–1.8) which corresponded to a median relative decrease of 35.8% (range = 16.2–76.3).

Prevalence of SDB

Twenty-nine subjects (48%) were diagnosed with mild SDB and eight subjects (13%) with moderate-to-severe SDB. Table 1 compares patient characteristics between these groups. Subjects with moderate-to-severe SDB had lower values of BMI z score, waist circumference, and percentage body fat as compared to the mild SDB group. These differences persisted after adjusting for sex and age. Tonsil size tended to enlarge by increasing severity of SDB. (Table 1). Snoring, daytime fatigue, behavioral problems, witnessed apnea, shortness of breath during sleep, and enuresis nocturna increased in frequency over the three groups, whereas the number of subjects who underwent adenoidectomy decreased (Table 1). Finally, there was a trend for an association between SDB category and Epworth sleepiness score, concentration and learning difficulties, and allergy. Overall, waist-to-hip ratio correlated with AHI (r = 0.29; P = 0.04). In the subgroup of children with mild SDB, tonsil size correlated with ODI (r = 0.47; P = 0.04), ₂> (r = -0.55; P = 0.01), and AHI (r = 0.44; P = 0.07). In the subgroup of subjects with AHI  5, waist circumference correlated with AHI (r = 0.81; P = 0.03), ODI (r = 0.78; P = 0.02), ₂> (r = -0.79; P = 0.02), and SaO₂nadir (r = -0.73; P = 0.04).

The effect of weight loss on the severity of SDB

Of 37 subjects with SDB, 21 had a follow-up sleep study after 5 months on average; 5 subjects refused to have a follow-up sleep study, 6 subjects had already left the center, and the oxymeter malfunctioned in 5 other subjects. There was no difference in anthropometric characteristics, but subjects without a follow-up screening (n = 16) had less severe SDB at the baseline study as expressed by a significantly lower frequency of subjects with moderate-to-severe SDB (6 vs. 33%; P = 0.05), a lower AHI (3.2  1.7 vs. 8.7  14.0; P = 0.01) and ODI (1.8  0.8 vs. 5.0  6.9; P = 0.02), a higher SaO₂nadir (89.4  4.6 vs. 85.7 5.5; P = 0.006) and percentage of time with SaO₂  90% (99.8  0.8 vs. 96.9 6.5; P = 0.03).

After a median weight loss of 24.0 kg (range = 11.0–48.0) which corresponded to a relative decrease in BMI z score of 34.8% (16.2–76.3%), 8 out of 21 subjects (38%) continued to have residual SDB, defined as AHI  2. The frequency of moderate-to-severe SDB significantly decreased from 33 to 9% (P = 0.05). Of these 21 subjects, 71% had ODI  2 at the time of the baseline study which also significantly decreased to 19% at the time of the follow-up study (P <>z score significantly correlated with the change in AHI (r = -0.51; P = 0.03) and in ODI (r = -0.61; P = 0.004) in these 21 subjects. We also calculated the ratio of the improvement in AHI, ODI, ₂>, SaO₂nadir and percentage of time with SaO₂  90%, and the relative decrease in BMI z score for subjects with mild and moderate-to-severe SDB. Only the decrease in ODI per unit decrease in relative BMI z score was significantly higher in the moderate-to-severe group (median = -0.10; range = -0.45 to -0.03) than in the mild sleep apnea group (median = -0.03; range = -0.45 to -0.03; P = 0.04).

Subjects with residual SDB (AHI  2 at follow-up study; n = 8) were younger (12.8  3.2 vs. 15.5  1.8; P = 0.02), had a higher AHI at the baseline study (median = 5.0; range = 2.6–58.3 vs. median = 3.5; range = 2.2–34.3; P = 0.08) and reported more habitual snoring (100 vs. 45%; P = 0.09) as compared to their peers who normalized their breathing pattern. There was no difference in BMI zscore at baseline (P = 0.7), relative decrease in BMI z score (P = 0.5), or in tonsillar size (P = 0.8) between both groups.

The association between the presence of SDB at baseline and the amount of weight loss achieved

Subjects with SDB at the time of the baseline study lost more weight as compared to their peers without SDB. This finding was more pronounced in subjects with moderate-to-severe SDB. The AHI of the baseline screening study correlated significantly with the relative (r = 0.28; P = 0.05) decrease in BMI zscore. This association remained significant after controlling for gender, age, initial BMI z score, and time between initial and follow-up study . Both ODI (partial r = 0.42; P = 0.003) and ₂> (partial r = -0.41; P = 0.003) at the time of the initial sleep screening were also associated with a higher relative decrease in BMI z score, adjusting for the parameters . Similar results were found with the absolute decrease in BMI z score as outcome variable which was significantly correlated with baseline AHI (partial r = -0.37; P = 0.01), ODI (partialr = -0.39; P = 0.002) and ₂> (partial r = 0.37; P = 0.003), controlling for the variables.

Discussion

In this study, the prevalence of SDB was 61%. This percentage is in agreement with previously published studies (10). Previous studies reported similar associations between SDB, daytime fatigue, behavioral problems, and enuresis nocturna (24,25,26). A higher prevalence of allergy and larger tonsil size, combined with the significantly lower frequency of adenoidectomy in the SDB groups suggest that upper airway factors also contribute to the pathogenesis of SDB in obese teenagers. However, our findings indicated that tonsil size correlated with the severity of SDB mostly in subjects with mild SDB. However, abdominal adiposity predicted the severity of SDB in subjects with moderate-to-severe sleep apnea. This is in line with previous reports which have shown that both adiposity and adenotonsillar hypertrophy modulate the severity of SDB in obese children and adolescents (2,3,4,5,27,28,29,30). Although the exact implications of these findings remain unclear for this study, we would like to recommend more imaging studies to elucidate the exact roles of adiposity and adenotonsillar hypertrophy in the pathogenesis of SDB in obese children. Nevertheless, the finding that weight loss was successful in treating SDB in 62% of our population (n = 21) suggests that adiposity played a major role in its pathogenesis. This number was even higher when using other markers of treatment success including AHI <>z score.

Scarce reports have assessed the influence of weight loss on SDB in children and adolescents. Unfortunately, these reports studied severely obese adolescents only. Siegfried et al. studied 38 severely obese adolescents and young adults (mean age of 18.0 years) who were also admitted to a revalidation center. The prevalence of SDB defined as AHI > 5 was 24%. In this group, mean AHI decreased by ~50% after weight loss, with three patients having residual SDB (14). This success rate was comparable to that reported in this study. Both studies clearly show the potential of nonsurgical-induced weight loss as a treatment for sleep apnea in severely obese adolescents. Second, Kalra et al.studied 34 severely obese patients who underwent bariatric surgery. The preoperative mean age was ~17.5, and the average BMI was 57 kg/m². At baseline, 55% of the subjects were diagnosed with obstructive sleep apnea syndrome, defined as AHI  5. After surgical weight loss, AHI, arousal index, and saturation parameters all improved, and only one subject continued to experience residual SDB (15). Finally, it is also important to note that one study in younger children between 7 and 11 years found that exercise—independent of changes in BMI—improved snoring and reduced the risk of SDB assessed by questionnaire (31). Although all these studies clearly show that weight loss can be an effective 

treatment for SDB in obese children, there is a subset of subjects with residual sleep apnea. In our study, these subjects were younger and had more severe SDB at baseline. There is thus a clear need for further studies investigating possible risk factors for residual sleep apnea after weight loss and for further studies assessing the combined effect of weight loss and upper airway treatment (adenotonsillectomy, pharmacological) on the severity of SDB in obese children and adolescents. Furthermore, further follow-up studies will need to assess how the weight loss obtained in this study was maintained.

An important clinical finding is that the severity of SDB at the initial screening study was positively associated with the amount of weight loss achieved during ~5 months therapy. The finding that this association was significant for both the absolute and relative improvement in BMI z score and that its significance remained after adjustment by the baseline BMI z score implies that different degrees of obesity between groups at baseline were not responsible for this association. Several factors can be proposed to explain this association. A first possible explanation is provided from studies which demonstrated that obstructive sleep apnea is associated with increased energy expenditure during sleep both in children (32,33) and in adults (34). Second, this correlation could also be mediated by the lower values of percentage body fat in subjects with more severe SDB or reversed by higher values of fat-free mass. The fat-free mass is the most important predictor of the resting metabolic rate, and there is also a strong relationship with total daily energy expenditure (35). Unfortunately, indirect calorimetry was not performed in this study, so we could not investigate a possible correlation between the SDB and the resting metabolic rate. There are a limited number of reports and none in children which studied the association between sleep apnea and resting metabolic rate. Two studies in adults found no effect of treatment of sleep apnea on resting metabolic rate (36,37). Finally, because staff and patients were only aware of the results of the first sleep screening a few weeks before the control study, it is not expected that this additional motivation for weight loss would have had a large impact on the present results.

In view of previous pediatric studies, the present findings clearly show the positive interrelationship between weight loss and the severity of SDB. However, the findings of our study should be reflected on considering the following study limitations. First, because a full polysomnography was not performed, we were unable to differentiate between obstructive and central events and to assess the influence on sleep architecture. Furthermore, the absence of arousal measurements could underestimate the number of hypopneas and hence AHI. Second, 16 subjects with SDB did not undergo a follow-up sleep screening for various reasons. A comparison of the baseline characteristics of subjects with and without a follow-up study showed that the latter group had a milder severity of disease. Therefore, it is not expected that subjects would have had a major influence on the success percentage. Third, the amount of weight loss generated by a residential treatment program in a specialized residential treatment center is probably not comparable with programs in outpatient clinics. Because we only performed one control sleep screening, we were unable to determine the amount of weight loss necessary to normalize breathing patterns during sleep. Therefore, we recommend further studies on the effect of modest weight loss on SDB in outpatient pediatric obesity clinics. Fourth, the subjects studied were aged 10 years of older. Our findings do therefore not necessarily apply to younger overweight children with SDB, in whom adiposity could contribute to a lesser extent to the pathogenesis of SDB compared to upper airway factors (38).

In conclusion, this study demonstrated that weight loss is successful in treating SDB in obese teenagers. Furthermore, there was a positive association between the severity of SDB and the amount of weight loss. These findings are in favor of considering weight loss as a first-line treatment for SDB in obese children and adolescents. However, more studies are warranted to confirm our findings in children younger than 10 years and to study the effect of modest weight loss on the severity of sleep apnea.

Disclosures

S.L.V. and W.D.B. are members of the board of directors of FluidDA N.V. L.V.G. is supported by a grant from the FWO-Flanders (G.0028.05).

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Acknowledgements

We thank Martine De Clerck, nurse, and Ann Tanghe, psychologist, for their kind cooperation in this study. We also thank ResMed for providing the ApneaLink devices for this study. This sponsor had no role in the study design; the collection, analysis, and interpretation of data; the writing of the report; and the decision to submit the article for publication.

Courtessy:NATURE journal

Meditate your way to a bigger brain

NEW YORK: Push-ups, crunches and gyms are fine for building bigger muscles and stronger bones. But can you meditate your way to a bigger  brain?  The answer is yes, as a new study has established that certain regions in the brains of those meditating long-term were larger than in a similar group.  A group of researchers at the University of California Los Angeles (UCLA), used high-resolution magnetic resonance imaging (MRI) to scan the brains of people who meditate.  Specifically, such people showed significantly larger volumes of the hippocampus and areas within the orbito-frontal cortex, the thalamus and the inferior temporal gyrus-regions known for regulating emotions.  "We know that people who consistently meditate have a singular ability to cultivate positive emotions, retain emotional stability and engage in mindful behaviour," said Eileen Luders, study co-author and postdoctoral fellow at the UCLA Lab of Neuro Imaging.  Luders and colleagues examined 44 people, 22 control subjects and 22 who had practised Zazen, Samatha and Vipassana meditation, among others. They had devoted an average of 24 years to the practice.  More than half of all the people who meditate said that deep concentration was an essential part of their practice, and most meditated between 10 and 90 minutes daily, said an UCLA release.  The researchers used a high-resolution, three-dimensional form of MRI and two different approaches to measure differences in brain structure.  These findings were published in NeuroImage.

CONSTITUTIONAL DIAGNOSIS.

The meaning of the term constitution in macrobiotic terms is the body type we develop as a result of time spent in our mother's womb and the first seven years of childhood. Our constitution, unlike our condition, is relatively fixed and cannot be altered, thus if we are born with a congenital condition, we cannot heal it through dietary changes.

How to know what type of constitution we have, more yin or more yang, as this is significant in terms of setting up a macrobiotic dietary practice which will be balanced for us. The major constitutional feature of the human being is our sex, male or female. In terms of yin and yang the male is outwardly more yang than the female, whereas the female is more yang inwardly than the male.

When we approach the problem of determining our constitution we look at several facial and body features in terms of yin and yang which we use as a checklist as in the following table:

#	FEATURE	YIN	YANG
1	Height	Taller	Shorter
2	Face Shape	Rounder, elongated	More square, narrow
3	Eyebrows	Slanted down and outward from the center of face	Slanted down and inward toward the nose
4	Eyes	Wide apart	Close set
5		More surface set	Deep set
6	Nose	Long	Short
7		Downturned	Upturned
8		Prominent	Flat
9	Mouth	Wide	Narrow
10	Teeth	Large and more spaced	Narrow and closer together
11		More slanted outwardly	More slanted inwardly
12	Chin	Narrow and pointed	More square
13		No cleft	Presence of cleft
14	Palm/Hand Proportion	Shorter palm, longer fingers	Longer palm, shorter fingers
15	Thumb position palm of hand fully extended	Thumb points away from face	Thumb curls back toward face
16	Fingers	Long, elegant, narrow	Shorter, squarer
17	Nails	Long and narrow	Short and square
18	Torso/Limbs Proportion	Shorter torso/longer limbs	Longer torso/shorter limbs
19	Feet	Long, broad	Shorter and more narrow

To determine whether we have a more yin or more yang constitution we simply check all our features on this list and total up the yin column against the yang column. There will always be in every individual an excess of either yin or yang features according to this list. So, having determined for ourselves whether our constitution is more yin or more yang, how does this effect our way of eating?

We know we have to eat in a balanced way. If we have a more yin constitution, then we eat more toward yang, and if we have a more yang constitution we eat more yin. However, when we factor in our condition we can therefore have four possible scenarios:

	Constitution	Condition
1	Yin	Yin
2	Yin	Yang
3	Yang	Yang
4	Yang	Yin

The problem, as you can readily acknowledge, is that if we have a more yang constitution we need to eat toward a more yin dietary intake but if we have a more yin condition we need to eat the opposite, a more yang dietary intake. So, how do we go about solving the need to eat in a more yin and a more yang way at the same time?

The way we do this is to look at the make-up of a macrobiotic dietary program in terms of yin and yang. As I have pointed out in the General Dietary Recommendations the macrobiotic way of eating consists of Whole Grains as Primary Food and Vegetables as Secondary Food. Now, whole grains are more yang than vegetables. Since whole grains are the foundation of the way of eating, we eat more grains relative to vegetables if we have a more yin constitution and if we have a more yang constitution we eat less grains and more vegetables.

When we want to determine how to eat for our condition we use the vegetables by noting that in the categorization I use in the General Dietary Recommendations that Roots and Ground Vegetables category is more yang than the Leafy Greens category. Thus if we have a more yin condition we eat more vegetables from the roots and ground vegetables category and less from the leafy greens. Whereas if we have a more yang condition we eat more leafy greens and less root and ground vegetables.

After you have used the Facial Diagnosis page to determine your condition and the Constitutional checklist above to determine your constitution, you can use the following table as a guideline for setting up your daily eating habits:

	WHOLE GRAINS	VEGETABLES
YANG Constitution YIN Condition	35-40%	50-55%
		ROOTS/GROUND	LEAFY GREENS
		1/2	1/2
YIN Constitution YANG Condition	45-55%	35-40%
		ROOTS/GROUND	LEAFY GREENS
		1/2	1/2
YANG Constitution YANG Condition	35-40%	50-55%
		ROOTS/GROUND	LEAFY GREENS
		1/3	2/3
YIN Constitution YINCondition	45-55%	35-40%
		ROOTS/GROUND	LEAFY GREENS
		2/3	1/3

These numbers are only to be used as guidelines, keeping in mind that you will be eating one bowl of miso soup daily and the vegetables you use in the soup do NOT figure into the above and you will be eating beans occasionally AND that you will be making adjustments according to the weather and climatic changes that occur in your locality of habitation.