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Obesity: An Expanding Clinical Crisis

400 million obese people worldwide and growing. In recent decades, the consequences of obesity have drastically shifted from a social and cosmetic issue to a serious epidemiological and clinical concern. The World Health Organization (WHO) estimates that there are at least 400 million obese people worldwide with nearly 20% of the worlds obese residing in the United States. If present trends continue, by 2015 this population could exceed 700 million people globally.

76 million obese people in the US, or one in three adult Americans. Within the United States, the last 30 years brought a dramatic increase in the obese population. In 1980 a National health and Nutrition Examination Survey (NHANES) estimated that 14% of US adults were obese. As of 2004, nearly one in three adult Americans suffered from obesity, with two in three adult Americans being categorized as wither overweight or obese.

The children are our future – and it is NOT pretty. The trends become even more frightening when we see the prevalence of overweight children rising to 17% in 2004 from 5% in 1980. Larger, fattier meals combined with a more sedentary lifestyle are poised to produce damaging and potentially deadly effects. Those who are overweight an obese carry higher risks for serious co-morbidities such as type 2 diabetes, heart disease, stroke, physiological changes that predispose adults to become obese.

Obesity will have a significant burden on our healthcare system. With the numerous complications associated with weight gain, these numbers highlight the colossal burden that will be placed on healthcare systems of all developed and developing countries, unless action is taken. The direct and indirect annual cost of obesity to the system in the US is already in excess of $200 billion.

Defining the obese patient

The most common formula used in classifying a person as obese or overweight is the Body Mass Index (BMI), which is weight/height2 (kg/m2). The clinical guidelines are as follows:

  • Underweight: BMI < 18.5
  • Normal: BMI between 18.5 – 24.9
  • Overweight: BMI between 25.0 – 29.9
  • Obesity, Class 1: BMI between 30.0 – 34.9
  • Obesity, Class 2 or Clinically Obese: BMI between 35.0 – 39.9
  • Obesity, Class 3 or Morbidly Obese: BMI between > 40
  • Obesity, Class 4 or Super Obese: BMI > 50

Once patients have been defined by a clinical classification of obesity, they can be given more appropriate care depending upon the severity of the condition. Also, with all of the complications stemming from weigh gain, the four different classes of obesity (obese, clinically obese, morbidly obese, and super obese) provide healthcare professionals with a more specific treatment algorithm to address the varying risks for developing co-morbidities.

Benchmarking patient progress

BMI is not perfect, but it is the best yardstick we have. While BMI has proven to be the best way to classify patients, it still has some flaws because it does not directly measure fat. What this means is that a person could be a lean 6’2 couch potato of the same weight.

Success is measured differently for devices and drugs. In order for researchers and patients to effectively compare results of different fat reduction therapies, there are a couple of metrics used for comparison:

  • Percentage excess weight loss (%EWL) reduction has become a common benchmark for surgical procedures and medical devices. The calculation is (weight loss) / (excess weight) X 100. Excess weight is defined as the difference between the actual weight and the “ideal weight”, based on an individual’s height and the weight that they would need to have in order to yield a BMI of 25. For example, a 6’ person weighing 300lbs would have a BMI of 41 (Morbidly Obese) and be carrying approximately an extra 115lbs. Weight loss of 60 pounds would result in a %EWL of 52% (60/115).
  • Percentage weight loss is a metric more used by diet, exercise, and drug therapies. It is calculated by (weight loss) / (original weight) X 100. Alternatively, a 6’ person weighing 300lbs and losing 60lbs would be reported as 20% weight loss.

Alcohol and Blood Glucose

Alcohol contains sugar and will initially raise your blood glucose level. However, in larger quantities, alcohol prevents your liver from releasing glucose, therefore it can lower your blood glucose and increase the risk of a hypoglycemic attack.

Points to remember about alcohol

• Drinking a lot of alcohol can cause hypoglycemia if you are taking insulin or insulin-stimulating pills so be prepared and learn to recognize signs of a hypoglycemic attack.
• Drinking alcohol with a meal or some carbohydrate-containing food will reduce your risk of hypoglycemia.
• All alcoholic drinks are high in calories. Low-calorie misers such as diet cola, diet ginger ale, and diet tonic water help you avoid extra calories.
• Alcohol consumption is measured in units. One unit of alcohol is equal to half a pint of ordinary strength beer, or 1.5 fl oz (25ml) of sherry, vermouth, liqueur, or aperitif. There is also 1 unit of alcohol in one small glass (4.5 fl oz/125ml) of wine or 1.5 fl oz (25ml) of liquor.
• The maximum recommended daily intake of alcohol is two to three units for women and three to four for men. It is recommended that you have two alcohol-free days a week.

Working out your body mass index (BMI)

To find your BMI, measure your unclothed weight and your height. Trace a straight horizontal and vertical line from each measurement on the chart. The point at which the two lines indicates the weight range you are in. you can ten tell whether you need to gain weight, lose weight, or maintain your healthy weight.

Why weight and body shape matter

Why is my body shape relevant to diabetes?

If you carry extra fat around your waist rather than on your hips, you are at increased risk of developing heart and circulatory problems. Even if you are not overweight, your risk of heart disease is reduced if you have less fat around your waist than on your hips.

How do I know if I have too much fat around my waist?

Measure your waist t the widest point. If it is more than 40in (102cm) for a man or 34in (88cm) for a woman, your risk of heart disease is increased.

How do I measure my waist-to-hip ratio?

Measure your waist and hips at the widest points and divide waist size by hip size. For example, a waist size of 33in (82cm) and hop size of 41in (103cm) gives a waist-to-hip ratio of 0.80. More than 0.95 (for a man) or 0.85 (for a woman) increases your risk of heart disease.

Overweight and Obesity

According to the National Heart, Lung, and Blood Institute (NHLB), BMI is the common measurement used to determine weight status. Overweight, obesity, and extreme obesity are defined suing BMI as follows:

• Overweight – BMI 25.0-29.9
• Obesity – BMI 30 or above
• Extreme obesity – BMI 40 or above

Determining a Healthy Body Weight

According to the most recent National Health and Nutrition Examination Surveys (conducted between 2005 and 2006), more than 72 million American adults – about 1 in 3 men (or 33.3 percent) and 35.3 percent of women – are currently obese. Among children between the ages of 2 and 19, 16.3 percent are obese. Although obesity rates are still quite high, there was no measurable increase in incidence between 2003 and 2004.

There are many causes of obesity and overweight. A unique interaction between genes and environment contributes to the development of overweight and obesity. For many of us, being genetically susceptible to overweight or obesity coupled with living in an environment that promotes excess consumption of high-calorie, nutrient-poor foods and beverages is destined to cause weight gain that eventually leads to overweight or obesity.

Here are some of the many factors that play key roles in the development of overweight and obesity:

• Increased availability of high-calories, high-fat, and high-sugar foods and beverages that are easy to overconsume.
• Increased portion sizes of foods and beverages, especially those offered at restaurants, fast-food establishments, from vending machines, or wherever food is sold. People tend to consume more when offered larger portions than when offered smaller portions.
• More eating on the run and when distracted. People often consume more calories when they eat away from home, while driving, when listening to music, when socializing, or when otherwise on-the-go.
• Decreased physical activity because of unsafe neighborhoods, a lack of sidewalks or parks, and technological advances that make physical activity less of a necessity (for example, escalators, remote controls, and computers).

Health Implications

Although many people might think of overweight or obesity in terms of appearance, weighing more than what’s recommended can put you at increased risk for a variety of health, psychological, and social problems. Here are some of the many adverse health consequences that are associated with a higher body weight:

• Coronary heart disease
• Type 2 diabetes
• Cancers (including endometrial, breast, and colon)
• Hypertension (high blood pressure)
• Dyslipidemia (high total cholesterol or high levels of triglycerides)
• Liver and gallbladder disease
• Sleep apnea and respiratory problems
• Osteoarthritis
• Gynecological problems (including menstrual problems and infertility)

Having excess body fat – especially in your abdominal area – increases the risk of type 2 diabetes, high blood cholesterol, high triglycerides, high blood pressure, and coronary artery disease.

Determining A Healthy Body Weight

Body Mass Index

Body mass index (BMI) is a common measurement used to asses body weight; it is also an indirect but reliable way of gauging a person’s body fat level. BMI is determined from your weight and height. Here’s the formula for calculating it:

• BMI = weight (in pounds) divided by height (in inches, squared) and multiplied by 704.5

For example, here’s how a woman who weighs 130 pounds and is 5 feet 4 inches tall would determine her BMI using the formula:

1. Convert height to inches: 5 feet x 12 inches per foot = 60 inches; because the woman is 5 feet 4 inches, add 4 inches; height in inches = 64
2. Multiply answer from #1 by itself: 64x 64 =4096
3. Divide answer from #2 by 130: 4096 / 130 = 0.0317
4. Multiply answer from #3 by 704.5 to get BMI: 0.0317 x 704.5 = 22.36 = BMI

After you know your BMI, you can see which of the following weight categories it falls in:

• Underweight – BMI below 18.5
• Normal weight – BMI 18.5 – 24.9
• Overweight – BMI 25.0 – 29.9
• Extremely obese – BMI >= 40

Underweight

Although BMI can be a useful estimate of a person’s body fat level, it has some weaknesses; it might overestimate body fat levels in those who have a lot of lean body mass and are muscular, and it might underestimate body fatness in those who are older and have lost muscle mass.

BMI-for-age is used to determine weight status in children. Because body fatness changes as children grow, and because girls tend to have more body fat than boys, gender and age are used to determine BMI values. Pediatricians and registered dietitians can asses children’s BMIs to determine whether their body weight falls within a normal range or whether they are at risk for obesity or overweight.

Waist Circumference

Measuring your waist size is useful in both adults and children. Having more abdominal or visceral fat can increase your risk for diet-related diseases including cardiovascular disease, high blood pressure, and type 2 diabetes.

Waist circumference measurements are especially useful for those whose BMI is less than 35; for some populations, waist circumference helps predict the risk of chronic illness better than BMI.

Here’s how to measure your waist circumference using a simple tape measure:

1. Place the tape measure snugly (but not tightly) around the bare abdomen just above the hip bone; make sure the tape measure is parallel to the floor.
2. Relax, exhale, and then measure the waist in inches.

As your waist circumference increase, so does your risk for cardiovascular and other diet-related diseases; those especially at risk include:

• Nonpregnant women with a waist measurement greater than 35 inches
• Men with a waist measurement greater than 40 inches

Eat to Beat Disease

Using a tape measure periodically to keep track of your waist size is a great way to determine how you’re doing in terms of body fat level and body fat distribution.

Although there are no established norms for waist circumference in children, those who measure above the 90th percentile are more likely to have heart disease risk factors such as higher levels of triglycerides and lower levels of HDL or good cholesterol, as well as obesity-related diseases and conditions.

Overweight and Obesity

A pediatrician can monitor your child’s waist circumference (measured at the end of the lowest rib after your child has taken a normal breath) at her annual checkup as part of an overall health assessment.

Visceral fat, also known as abdominal fat, is fat that accumulates around internal organs. This fat is more dangerous than other types of body fat because it’s believed to secrete potent hormones and other chemicals that increase the risk of cardiovascular and other diseases.