REVIEW
Comprehensive Evaluation for Obesity:
Beyond Body Mass Index
Derrick Cetin, DO
Bailey A. Lessig, OMS II
Elie Nasr, BA
From the Bariatric and
Metabolic Institute at the
Cleveland Clinic in Ohio.
Many factors contribute to the diagnosis of obesity in a patient. Anthropometric
measurements, such as the waist circumference and percentage of body fat, are
This manuscript is based
used in the newly released obesity algorithm to risk stratify patients. Staging
on a presentation given at
methods, which use the identification of comorbidities and disease burden to
the Osteopathic Medical
Conference and Exposition
assess the severity of obesity, can result in treating a patient sooner than if the
in Seattle, Washington,
traditional body mass index is used. Obesity is a growing concern in the medi-
in October 2014.
cal field, and providing additional avenues through which to diagnose obesity
Financial Disclosures:
and address obesity-related health risks can improve prevention efforts and
None reported.
lead to expedited weight management. Obesity is a growing concern in the
Support: None reported.
medical field, and providing additional avenues through which to diagnose
Address correspondence to
obesity and address obesity-related health risks can improve prevention ef-
Derrick Cetin, DO,
2367 Silveridge Trail,
Westlake, OH 44145-1791.
E-mail: [email protected]
Submitted
March 4, 2015;
final revision received
February 29, 2016;
accepted
March 18, 2016.
forts and lead to expedited weight management.
J Am Osteopath Assoc. 2016;116(6):376-382
doi:10.7556/jaoa.2016.078
M
ore than one-third of adults and one-sixth of adolescents in the United States
are obese.1 A patient is considered obese if he or she has a body mass index
(BMI) greater than 30.2 The prevalence of obesity has doubled since 1994,3
and between 2000 and 2010, the prevalence of morbid or extreme obesity (BMI ≥40)
increased 70% in the United States, from 3.9% to 6.6%.4 During the past 20 years, the
number of people in the United States with BMIs greater than 30, 40, and 50 have doubled,
quadrupled, and quintupled, respectively.2 Approximately 100 million people are overweight (BMI, 25-29.9), 85 million people are obese, and 15 million people are morbidly
obese.5 In this article, we describe the tools that have been used historically to diagnose
obesity and outline new efforts to redefine important early markers for obesity and obesityrelated health risks in patients.
Definition of Obesity
Body mass index is the standard for classifying weight and is the most practical method
to determine the extent of obesity. It also correlates fairly well with underlying body
fat. There are some pitfalls in using BMI to determine body fat, however, as it does not
differentiate between lean muscle mass and fat mass. In a young healthy athlete, BMI
can overestimate body fat, especially if it is in the overweight range. In older people,
BMI can underestimate underlying body fat, owing to the loss of muscle mass with
aging, called sarcopenia. This age-related loss of muscle mass in addition to an
increase in fat mass is called sarcopenic obesity and represents a redistribution of fat
mass and fat-free mass. Patients with sarcopenic obesity have a relative increase in
376
The Journal of the American Osteopathic Association June 2016 | Vol 116 | No. 6
REVIEW
intra-abdominal fat that is greater than subcutaneous
at lower BMI cutoff points.8 Using the recommended
or total body fat and a relative decrease in peripheral
BMI cutoff points ensured earlier screening and diag-
fat that is greater than central fat-free mass resulting
nosis of T2DM. In 2006, the International Diabetes
from the loss of skeletal muscle.
Federation (IDF) suggested ethnic-specific values for
6
waist circumference (WC) in an effort to identify central
obesity, a causitive factor in metabolic syndrome, in
Ethnic Differences
in Measuring Obesity
specific ethnic groups (Table 1).10
A 2006 study7 suggested that current overweight, obesity, and central adiposity guidelines based on white
Obesity-Associated Disease Risk
populations are not appropriate for other ethnic popu-
BMI and Waist Circumference
lations, such as Asians, Hispanics, and blacks. The
Determinants
Nurses’ Health Study highlighted the ethnic differ-
Body mass index is not only used to classify obesity but
ences in BMI. In the study, 78,000 US women without
also to determine life expectancy and prevalence of
type 2 diabetes mellitus (T2DM) had their weight
obesity-related issues and comorbidities. The risk of
tracked for 20 years to determine whether any ethnic
developing a comorbid condition increases with in-
differences in the development of T2DM existed. It
creasing BMI.11
was observed that Asians had more than double the
risk of T2DM compared with whites with the same
overweight and class I and II obesity groups are large
BMI.7 The risk of T2DM was also increased in His-
WC (>40 in [102 cm] in men and >35 in [88 cm] in
panics and blacks, but to a lesser degree.7 Similar find-
women), poor aerobic fitness, and ethnicity.11 The ratio-
ings were noted in a multiethnic cohort study of 59,824
nale for measuring the WC in clinical practice is to
nondiabetic adults.8 Type 2 diabetes mellitus devel-
identify metabolically obese and overweight patients
oped in South Asian, Chinese, and black participants at
whose BMI is normal and thus would not be considered
a lower BMI, younger age, and higher rate compared
for lifestyle intervention and treatment. The WC mea-
with their white counterparts. The expert opinion of
surement has been highlighted as a key component in
the World Health Organization concluded that Asians,
several recently released algorithms for overweight and
in general, have a higher percentage of body fat com-
obesity management.11,12 Waist circumference is also a
pared with whites of the same age, sex, and BMI.9 The
method often used to diagnose metabolic syndrome in
report also concluded that the Asian population has a
overweight and obese patients. When a large WC is
higher risk for T2DM and cardiovascular disease at a
factored into BMI-associated disease risk, there is an
lower BMI (25) compared with other ethnicities. Ob-
increased disease risk in the overweight and class I
served risk in different Asian populations was noted at
obesity groups (Table 2).
BMI cutoff values between 22 and 25, with high risk
between 26 and 31.9
mains unchanged in obesity classes higher than class II
7
8
9
Additional factors that increase disease risk in the
The additional risk brought on by a large WC re-
The expert opinion made no attempt to redefine the
because WC has little added predictive power of disease
existing BMI cutoffs and did not indicate a specific
risk beyond that of BMI. The WC, therefore, is less
BMI cutoff for overweight and obesity. Rather, in-
useful as an independent marker of medical risk when
creased risk was identified for the BMI continuum, and
the BMI is greater than 39. Overall risk is independently
public action points were recommended for intervention
associated with excess abdominal fat (WC >40 inches
The Journal of the American Osteopathic Association June 2016 | Vol 116 | No. 6
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Table 1.
Ethnic Specific Values for Waist Circumference in Central
Obesity From the International Diabetes Federation
Consensus World Wide Definition of Metabolic Syndrome
Treatment Panel III, it has been estimated that 1 in
3 adults living in the United States has metabolic syndrome.14 The finding of central or visceral obesity is a
Male Female
prerequisite risk factor for metabolic syndrome ac-
United Statesa
≥102 cm or 40 in
≥88 cm or 35 in
cording to the IDF consensus definition.10 For a diag-
Whites
≥94 cm or 37 in
≥80 cm or 31 in
nosis of metabolic syndrome, central obesity is
South Asians,
Chinese, Japanese
≥90 cm or 35 in
≥80 cm or 31 in
required in addition to any 2 of the following condi-
South and Central
Americans
Use criteria for South Asian until
more specific data are available
low high-density lipoprotein level (<40 mg/dL in
Sub-Saharan Africans,
Eastern Mediterranean
and Middle East (Arab)
Use criteria for whites until more
specific data are available
(>130/85 mm Hg or current hypertension treatment),
Population a
According to the clinical criteria developed by Adult
tions: elevated triglyceride level (≥150 mg/dL),
males, <50 mg/dL in females), elevated blood pressure
and impaired fasting plasma glucose (>100 mg/dL). 10
The intra-abdominal deposition of visceral fat is a
In the United States, the values shown based on the Adult Treatment
Panel III are likely to continue to be used for clinical purposes.
major contributor to the adverse metabolic conse-
Source: Adapted from Garvey WT, Garber AJ, Mechanick JI, et al; AACE Obesity
Scientific Committee. American Association of Clinical Endocrinologists and American
College of Endocrinology position statement on the 2014 advanced framework for
a new diagnosis of obesity as a chronic disease. Endocr Pract. 2014;20(9):977-989,
with permission from the American Association of Clinical Endocrinologists.
quences mediated by the release of proinflammatory
cytokines, resulting in insulin resistance and endothelial dysfunction. Hence, abdominal obesity is associated with multiple cardiometabolic risk factors, such as
atherogenic dyslipidemia (hypertriglyceridemia and
in men and >35 inches in women). The visceral deposi-
low high-density lipoprotein level), elevated blood
tion of adipose tissue is easily ascertained by measuring
glucose level, and inflammation, which are major
WC or the waist-to-hip ratio.
drivers of cardiovascular disease and T2DM. To ap-
Waist circumference was shown to be a surrogate
propriately diagnose metabolic syndrome, patient eth-
marker for intra-abdominal adiposity in a study of 81
nicity must also be considered. Not only does
men and 70 women.13 In this study, WC strongly cor-
metabolic syndrome affect 1 of 3 adults in the United
related with intra-abdominal adiposity as measured
States, it is estimated that one-fourth of adults world-
using computed tomography or magnetic resonance
wide have this condition.10
11
imaging, which are considered the criterion standards
for imaging adipose tissue.13 In 1998, an expert panel
Comorbid Conditions
organized by the National Heart, Lung, and Blood Insti-
More than 30 comorbid conditions associated with
tute recommended that WC be measured as part of the
severe obesity exist, including dyslipidemia, hyper-
initial assessment of overweight and obese patients
tension, sleep apnea, and T2DM.15 Obesity is also
(BMI <35) and be used to monitor the efficacy of
associated with an increased risk for coronary heart
weight loss therapy.
disease. A recent meta-analysis noted a 29% increase in
11
coronary heart disease for each 5-unit increase in BMI.16
378
Metabolic Syndrome
Risk is accelerated by the coexistence of other fac-
The increased disease risk in the overweight and class
tors, such as those listed above. In the Framingham
I obesity groups can be explained by metabolic syn-
Heart Study, obesity was observed to be an indepen-
drome, also known as insulin-resistant syndrome.
dent risk factor for all-cause mortality in a 30-year
The Journal of the American Osteopathic Association June 2016 | Vol 116 | No. 6
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Table 2.
Disease Risk Relative to Normal Weight and Waist Circumference
Waist Circumference
Weight
BMI
Underweight
Obesity
Men, <40 in; Men, >40 in;
Class
Women, <35 in
Women, >35 in
<18.5…
…
…
Normal
18.5-24.9…
…
…
Overweight
25.0-29.9…
Increased
High
Obese
30.0-34.9
35.0-39.9
Extreme obesity
>40.0
I
High
Very high
II
Very high
Very high
III
Extremely high
Extremely high
Abbreviation: BMI, body mass index.
Source: National Heart, Lung, and Blood Institute; National Institutes of Health; US Department of Health and Human Services.
follow-up of male participants.17 Multivariate anal-
(ACC), and The Obesity Society released the updated
yses revealed a strong positive association between
Guidelines for the Management of Overweight and
baseline weight and death rate for nonsmoking men
Obesity in Adults. 21 The American Association of
who were overweight (3.9 times higher than that of
Clinical Endocrinologists (AACE) and the American
men of normal weight). Another prospective study
College of Endocrinology (ACE) released a position
that followed more than 1 million adults for 14 years
statement on the 2014 Advanced Framework for a
noted a strong relationship between BMI and in-
New Diagnosis of Obesity as a Chronic Disease.22
creased risk for all-cause mortality and death due to
All 3 guidelines use BMI and WC to establish the diag-
cardiovascular disease in nonsmokers and in men and
nosis of overweight or obesity and take into account the
women with no history of coronary heart disease.18
ethnic differences established by the IDF.
In the Nurse’s Health Study, among 43,581 women
who did not have T2DM, after adjustments for age,
common recommendations on when to initiate weight
family history of diabetes, smoking, exercise, and
loss medications, refer a person for bariatric surgery,
dietary factors, the relative risk for developing T2DM
and establish goals for treatment. All of the recom-
at a BMI of 29 vs 20 was 11.2.
mendations stress that weight loss between 3% and
17
19
Our comparative analysis of all guidelines revealed
10% should improve overall health and health-related
Defining Obesity Beyond BMI
targets. The OMA also included the most complete
recommendations for appetite suppressants for weight
In 2013-2014, 3 algorithms for the treatment of over-
loss. The AACE/ACE and the OMA endorse the ear-
weight and obese adults were released. In 2013, the
lier use of appetite suppressants in patients who are
American Society of Bariatric Physicians, now called
overweight or obese, especially if medical complica-
the Obesity Medicine Association (OMA), released the
tions exist. The AACE/ACE and the AHA/ACC will
Obesity Algorithm.
include updates on weight loss medications in future
20
In 2013, the American Heart
Association (AHA), American College of Cardiology
supplements to the initial algorithms.
The Journal of the American Osteopathic Association June 2016 | Vol 116 | No. 6
379
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AACE/ACE Advanced Framework
bolic syndrome criteria or the presence of insulin resis-
for a New Diagnosis of Obesity
tance. Thirty percent of this group had insulin
The algorithm developed by AACE/ACE recommends
resistance, and 38.4% had 2 or more criteria for meta-
that the goals for treatment should be based on the se-
bolic syndrome. Although the MNOB phenotype is
verity of obesity-related complications, such as meta-
rare, an increase in all-cause mortality was noted in this
bolic syndrome, prediabetes, T2DM, dyslipidemia,
group, with a hazard ratio of 2.58 for insulin resistance
hypertension, nonalcoholic fatty liver disease, poly-
and 2.80 for metabolic syndrome criteria. In the
cystic ovary syndrome, sleep apnea, osteoarthritis,
MAOB, the hazard ratio was 3.09 for insulin resistance
gastroesophageal reflux disease, and difficulties with
and 2.74 for metabolic syndrome criteria. This study23
mobility. The AACE/ACE guidelines developed an
emphasized the importance of treating the obese popu-
advanced framework for a new diagnosis of obesity
lation even if insulin resistance and metabolic syn-
that does not totally depend on BMI.22 They define
drome are absent. Intensive lifestyle modification,
normal weight, depending on ethnicity, as a BMI less
behavioral therapy, and weight management should be
than 25 and a WC that does not exceed the cutoffs rec-
the cornerstone for reducing morbidity and mortality in
ommended by the IDF worldwide definition of meta-
the MNOB population.
bolic syndrome.
In certain ethnic populations, a BMI of 23 to 25
obesity. Patients with a BMI of 30 and those with a
Primary, Secondary, and
Tertiary Prevention and Treatment
BMI of 25 to 29 with no obesity-related complica-
The AACE/ACE’s algorithmic approach to the diag-
tions are categorized as overweight. If BMI is greater
nosis, evaluation, and care of obese patients takes into
than 25, the presence or absence of severity of spe-
account BMI and the extent to which being overweight
cific obesity-related complications defines whether
or obese has affected patients’ health or the severity of a
the patient is overweight or obese.22 The presence of
specific health condition.
1 or more mild to moderate obesity-related complica-
tions defines stage 1 obesity. The presence of 1 or
ment algorithm focuses on primary prevention. Edu-
more severe obesity-related complications defines
cating patients to adopt healthy eating patterns,
stage 2 obesity.22
increase physical activity, and improve sleep hygiene
and increased WC for ethnic-specific values indicates
For patients whose weight is normal, the treat-
are some of the strategies used to prevent weight
380
Metabolically Normal Obesity
gain in these patients. For patients who have over-
Overweight or obesity stage 0 may represent the meta-
weight or obesity stage 0, the focus is on secondary
bolically normal obese (MNOB) population. This des-
prevention. Strategies that prevent progressive
ignation was noted in a prospective study of 6011 obese
weight gain and the emergence of obesity-related
men and women participating in the Third National
complications are similar to the treatment techniques
Health and Nutrition Examination Survey (NHANES
for normal-weight patients but with intensive life-
III).23 It was determined that 6% of the MNOB group
style and behavioral therapy and the consideration of
(or 1.6% of the general obese population) did not have
pharmacotherapy for weight loss. Emphasis on
insulin resistance and did not meet any of the metabolic
weight loss is recommended if the BMI is 30 or
syndrome criteria. The metabolically abnormal obese
higher or if weight gain has been progressive. Pa-
(MAOB) group was defined as having 2 or more meta-
tients with stage 1 or 2 obesity enter a tertiary pre-
The Journal of the American Osteopathic Association June 2016 | Vol 116 | No. 6
REVIEW
vention pathway that provides strategies to prevent
with targeted weight loss. If the health condition
worsening of the underlying health conditions and to
cannot be improved because of suboptimal weight
manage complications.
loss, then pharmacotherapy and, eventually, bariatric
surgery are considered.
A 5% to 10% weight loss through diet and increased
physical activity has been shown to induce a 30% or
more loss of visceral adipose fat.24 Mobilization of ath-
land Clinic applies 2 of the fundamental principles of
erogenic visceral fat substantially reduces the risks of
osteopathic medicine to treat patients with obesity.
adverse consequences of metabolic syndrome.13 Prefer-
Every patient on track for weight loss surgery must be
ential mobilization of visceral fat explains the improve-
counseled and cleared by a physician, dietician, psy-
ments in atherogenic dyslipidemia, insulin sensitivity,
chiatrist, and surgeon before proceeding to surgery.
and hypertension. Studies are in progress to assess the
The process to become eligible for weight loss surgery
cardiometabolic risk profile after weight loss and mobi-
evaluates the body and mind to confirm that each pa-
lization of visceral fat.
tient is prepared to make this drastic change. The goal
of the surgery is to lose the excess weight so the body
25
26
Once complications develop in patients with over-
weight or obesity stage 0, it is assumed that the in-
The Bariatric and Metabolic Institute at the Cleve-
can begin to heal itself.
creased weight is affecting their health. At this point,
treatment should transition from the secondary to the
tertiary phase of treatment.22 Patients with stage 1
Conclusion
obesity can achieve improvement in obesity-related
At any given BMI, an elevated WC is a good surrogate
complications with weight loss in the range of 3% to
marker of increased abdominal fat, as increased vis-
10%. Patients with stage 2 obesity tend to have a
ceral fat vs subcutaneous fat distribution is not only a
greater burden of associated complications in overall
key feature of metabolic syndrome but also a driver of
health. Recommendations for this group are weight
increased cardiometabolic risk. The OMA, AHA/
loss of 10% or more. Intensive lifestyle and behavioral
ACC, and AACE/ACE guidelines go beyond BMI and
therapy and weight loss medications are also recom-
WC measurements, however, and use staging systems
mended for patients with stage 1 or 2 obesity. Bariatric
that analyze body fat percentage and determine the
surgery is a consideration for patients with T2DM and
burden of fat mass or adiposity on patients’ health.21-23
a BMI of 35 or higher.21 Laparoscopic gastric banding
The AACE/ACE staging system uses lower BMI and
is also indicated for a BMI greater than 30 and 1 or
WC cutoffs than the OMA, and their guidelines em-
more adverse health consequences.27 Since the mid-
phasize identifying the disease burden at an earlier
2000s, however, more bariatric surgeons have been
stage and recommend strategies to prevent the pro-
performing the laparoscopic sleeve gastrectomy than
gression of the disease process. All 3 obesity guide-
gastric banding.
lines recommend initiating treatment strategies before
28
The treatment of overweight and obese patients
complications develop. These guidelines are available
always recognizes the importance of managing com-
as tools to screen patients who may have an increased
plications even when a patient is not involved in a
burden of disease, including metabolic syndrome, es-
weight loss program. The goals of the treatments
pecially those with normal-weight obesity (normal
outlined in the AACE/ACE algorithm focus on im-
body weight but high fat percentages), in an effort to
proving health conditions such as hypertension,
prevent cardiovascular events and reduce morbidity
T2DM, and hyperlipidemia, which can be achieved
and mortality.
The Journal of the American Osteopathic Association June 2016 | Vol 116 | No. 6
381
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© 2016 American Osteopathic Association
The Journal of the American Osteopathic Association June 2016 | Vol 116 | No. 6