21 Obesity and its Implications: Physical and Psychosomatic health

Urvashi Gupta and Meenal Dhall

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Contents:

 

1.      Introduction

2.      Assessment of obesity

2.1 Anthropometric techniques

2.1.1 Points to be noted about anthropometry

2.1.2 Different perceptions about anthropometry

2.2 Non anthropometric techniques

2.2.1 Densitometry

2.2.2 Imaging

2.2.3 Bioelectrical impedance

3.      Implications of obesity

3.1 Effects on physical health

3.2 Psychosocial impacts Summary

 

Learning Objectives:

 

1.  To know and understand various aspects associated with obesity.

2.  To develop an understanding about the anthropometric methods of assessing obesity.

3.  To understanding different non-anthropometric methods of assessing obesity.

4.  To know about the physical and psychosomatic implications of obesity.

 

1. Introduction

 

Weight is gained more frequently at certain ages or physiological periods. In women, this is most likely after the completion of growth at about the age of 20 years, during pregnancy, and after menopause. Men tend to gain weight between the ages of 25 and 40 years. It has been shown that persons overweight as children, teenagers, or young adults are likely to remain or become more overweight throughout life. Fat accounts for a higher percentage of total body weight in females than in males at all ages. Body fatness for both sexes increases with age. In adult life, it increases at a faster pace for men than women; yet, women at all ages are on the average fatter than men.

 

Overweight can be defined as the ratio of actual weight to average or desirable weight, specific for age, sex, height and body build. An individual may be overweight on account of musculature or bony structure rather than excess fat, so that overweight and obesity are not necessarily synonymous. Obesity is defined as excessive body fatness. Obesity has always been a major public health problem. Its prevalence in the world has increased in the last few decades affecting both children and adults in all ethnic groups and populations.

 

It is a complex interplay between gene and environment that involves excessive accumulation of fat in body. Over the past few decades, obesity has gained a lot of attention not only in terms of research findings but also due to its epidemic nature that poses a negative risk over health and society. Though the situation is completely preventable and avoidable but even then it acts as the perpetrator for the incidence of several non-communicable, chronic disorders, thereby overburdening the society with high mortality and morbidity rates. Multiple factors contribute to the onset and progression of obesity. These are:

  • lifestyle
  • lack of physical activity
  • overeating/ unhealthy eating habits
  • genetic predisposition and family history
  • environmental factors
  • personal attributes
  • lack of willpower

   Global economy has lead to industrialization, thus resulting in change from traditional diets and labor intensive lifestyle. This has modified the overall pattern of living and change in food habits with consumption of modern calorie-rich diets that is also rich in fats and sugar content accompanied with sedentary lifestyle in many nations. Also it is very difficult to separate genetic and environmental influences that regulate obesity in an individual.

 

2. Assessment of obesity

 

Since the component of obesity that can be reduced is fat, so the determination of relative fatness is of practical significance. Obesity can be measured in many ways. Some methods are quite complex, such as densitometry or hydrometry, and determination of whole body potassium content; others are relatively simple, including measurement of subcutaneous skin folds, and soft-tissue X-rays. Each method has its own advantages and disadvantages, and the appropriateness and scientific acceptability of each method will depend on different situation. The assessment methods often measure different aspects of obesity – for example, total or regional adiposity. They also produce different results when they are used to estimate morbidity and mortality.

 

When there is increased body fat, there will also be necessary increase in some lean tissue, including the fibrous and vascular tissues in adipose tissue, heart muscle, bone mass, and truncal or postural musculature. All the non-fat tissues (Fat Free Mass) have a higher density (1.0 g/ml) than that of fat (0.7 g/ml). During regular physical activity the bulk of non-fat tissues increase and body fat decreases. In general, anthropometric measurements like body weight and stature, waist –hip ratio, waist –height ratio ,are used to reflect body fat in epidemiological studies or in clinic settings as such measurements provide a rapid and cheap way to estimate body fatness and fat distribution pattern. Densitometry or imaging techniques are used in smaller scale studies such as clinical trials. The Committee on Nutritional Anthropometry recommended triceps and subscapular skinfolds as methods for characterizing over-all fatness since subcutaneous fat makes up approximately half of the total body fat content.

 

2.1     Anthropometric techniques

 

Body mass index (BMI) has traditionally been used to identify individuals who are most likely to be overweight or obese. It is calculated by dividing the weight (in kilograms) by the height (in meters) squared. While measuring height, subject must stand straight with the back stretched to the maximum, arms hanging normally by the sides and the head oriented the Frankfort horizontal plane. For weight measurement subjects should ideally be naked or in light clothing and bare feet. Weight measurement be taken in fasting condition, and with empty bladder. Repeat measures are best made at same time of day.

 

Generally, a high value indicates excessive body fat and consistently related to increased health risks and mortality. The need to have a separate BMI classification was felt when it was found that Asians are at a greater risk of metabolic syndrome at lower BMI .Unusually large muscle mass, as in trained athletes, can increase BMI to 30, but rarely above 32. BMI categories and cut-offs are commonly used to guide patient management. BMI reference ranges assume health in other aspects—healthy weight may be lower with major muscle wasting. One of the basic and convenient methods of assessing obesity is indicated by Body Mass Index, but it fails to take into consideration the amount of fat deposited on the abdominal site.

 

However, waist circumference and Waist Hip Ratio (WHR) provide measure of abdominal adiposity with great ease and reliability, as they correlate more closely with abdominal adipose tissues. Waist circumference was developed initially as a simpler measure and a potentially better indicator of health risk than BMI. Waist circumference or minimum waist circumference measures the minimum circumference of the waist between the lower rib and iliac crest where minimum value is found. Waist circumference is at least as good an indicator of total body fat as BMI or skinfold thicknesses, and is also one of the best anthropometric predictor of visceral fat. For practical purposes, triceps skinfold measurement alone is considered adequate as being simple, reasonably precise, and reproducible.

 

Fig 1. Measuring triceps skinfold thickness using Holtain skinfold caliper

 

Table showing Cut offs of Waist circumference categories (Alberti et al., 2009)

 

People with increased fat around the abdomen or wasting of large muscle groups, or both, tend to have a large waist circumference relative to that of the hips (high waist to hip ratio). Waist circumference alone, however, gives a better prediction of visceral and total fat and of disease risks than waist to hip ratio. Waist circumference is minimally related to height, so correction for height (as in waist to height ratio) does not improve its relation with intra-abdominal fat or ill health.

 

Cut off points for Waist-height ratio (Ashwell, 2005)

 

People with a large waist are many times more at risk of ill health, including features of metabolic syndrome (such as diabetes, hypertension, and dyslipidaemia) as well as shortness of breath and poor quality of life. These increased risks also apply in people whose BMI is normal but who have a large accumulation of fat around waist. However, BMI and waist circumference are collinear, so combining the two measures adds relatively little to risk prediction.

 

BMI is still a useful guide to obesity related health risks, but waist circumference is a simple alternative with additional value for predicting metabolic and vascular complications. During weight loss, each kilogram of weight loss is equivalent to a reduction of about 1 cm in waist circumference. However, there is greater measuring error for waist circumference, so body weight is the best measure for monitoring the change.

 

Waist to hip ratio was introduced—mainly as a result of Swedish research—on the assumption that it would predict fat distribution better than waist circumference alone. Subsequent research, however, showed that it did not. Hip circumference does have a relation to health and disease, but in an inverse way, such that a relatively large hip circumference is associated with lower risks of diabetes and coronary heart disease. This is probably because hip circumference reflects muscle mass, which is reduced in type 2-diabetes and inactivity. It is a common measure of fat distribution. This ratio is an indicator of central obesity. Gender specific cut offs for abdominal obesity defined by waist to hip ratio (Willett et al., 1999) are as follows:

 

2.1.1 Points to be noted about anthropometry

  • Weight should be measured by digital scales or a beam balance to the nearest 500 g. Equipment should be calibrated regularly by standard weights and the results must be recorded in a book.
  • Patients should ideally be weighed in light clothing and bare feet, ideally fasting and with an empty bladder.
  • Height is measured with a regularly calibrated stadiometer. Patients stand in bare feet that are kept together. The head is oriented in Frankfort Horizontal Plane (an imaginary line from lower border of the eye orbit to the auditory meatus).
  • If a participant cannot stand for example, is confined to a chair or bed, BMI can still be derived from special equations using arm span or lower leg length instead of height.
  • Waist circumference should be measured between the lower rib margin and iliac crest wherever found minimum, with a horizontal tape at the end of gentle expiration.
  • Waist circumference measurement at the umbilical level is not reliable because sagging of abdominal skin occurs in very obese subjects or those who have lost weight previously.
  • During waist circumference measurement, participant should be asked not to hold in their stomach, and a constant-tension, spring-loaded tape device reduces errors from over-enthusiastic tightening during measurement.

    2.1.2 Different perceptions about anthropometry

  • The main difficulty with anthropometric measures is that doctors, scientists, and the public are not very much aware of the value of these measurements.
  • People often assume that technological devices such as fat analyzers are better at measuring body fat. This assumption often arises from better marketing of technology, yet no portable body fat analyzers (including those that measure bioelectrical impedance, which is highly dependent of body hydration status) are without assumptions and errors, than anthropometric measurements ,which remains the best predictors for assessing obesity, fat distribution pattern especially on a large scale population data.
  • Cut-off levels of waist circumference relating to increased health risks have not been fully defined for different ethnic groups, although some African and Asian groups clearly have a greater risk of coronary heart disease than Europeans at the same cut-off levels.
  • Two people of the same BMI may have very distinct body shapes, depending on the distribution of body fat and skeletal muscle.
  • A change in single measure, such as the amount of weight loss or reduction in waist circumference, is easily understood by lay man, whereas a ratio (such as waist to hip ratio or BMI) is more difficult to conceptualize.
  • Accuracy in measuring waist circumference can be improved with use of a specially designed tape measure, although a change in body fat may not be detected by waist circumference in very fat people, when the abdominal fat mass is pendulous.

    2.2 Non anthropometric techniques

 

2.2.1   Densitometry

 

Total body fat was classically measured by densitometry based on the Archimedes principles of water displacement, assuming just two body compartments modal: fat (density about 0.7 g/ml) and fat-free tissue (about 1.0 g/ml). Under this principle, if two individuals of the same weight on land have different proportions of body fat and lean tissue, the one with more body fat and less lean tissue would weigh less underwater.

 

Densitometry requires underwater weighing facilities, is time consuming and expensive. Furthermore, many people would not like to be submerged in water. Densitometry therefore cannot be used routinely. It also does not indicate body fat distribution.

 

2.2.2 Body Imaging

 

In the past decade, new imaging techniques such as computed tomography and magnetic resonance imaging allow discrete deposits of body fat to be imaged. Specific fat depots can be measured, including the visceral fat depots. These relate more strongly than subcutaneous fat to metabolic abnormalities. Fat in other structures, such as the liver, or muscle cannot be quantified easily. Imaging is very expensive and can be problematic for people who are claustrophobic and also carries risk of exposure.

 

Precise and accurate measurements of regional fat mass can be estimated from two dimensional, transverse, multiple slices. The fat volume estimated from a single slice based on regression equations can be used to reduce time, cost, and risk of radiation exposure for some purposes, such as repeated studies in the same patient. Other imaging techniques, including dual energy X-ray examination, are good predictors of visceral fat but, like computed tomography, expose subjects to radiation which limits their use in repeated measurements. They were originally calibrated against the gold standard – densitometry.

 

2.2.3 Bioelectrical impedance

 

Obese people have increased lean body mass as well as increased fat mass. Bioelectrical impedance estimates total body water, which is a constant component of lean body mass. As this technique is totally based on hydration level of the body, therefore estimation of fat mass by this technique may incur relatively more error.

 

It is important to note that the techniques like Densitometry, dual energy X-ray examination, Other imaging techniques are not convenient for large population surveys which are required to develop normal cutoffs due to the expenses ,time and exposure risk involved. Under such situations anthropometric techniques are the best ones, but for clinical diagnostic purpose and treatment the former are the answers.

 

3. Implications of obesity

 

3.1 Effects on physical health

 

Increasing body mass along with the accumulation of excess fat above the ranges recommended for a particular age group, ethnic group or gender could be very harmful as it not only affects the normal functioning of the body and organs but also acts as a trigger for the development of many other diseases. Based up on different studies and research works it has been estimated that of all the hypertensive cases, roughly around 30% could be categorized as obese.

 

Increased adiposity, especially related with the abdominal region, has been found to be associated with a large number of non-communicable disorders. It predisposes an individual to several health issues such as hypertension, cardiovascular diseases, lipid disturbances, insulin resistance, osteoarthritis, metabolic syndrome, respiratory abnormalities and some types of cancer. It affects the hemostatic and fibrinolytic system.

 

Obesity is an independent risk factor for cardiovascular disease including coronary artery disease and congestive cardiac failure. Visceral obesity is linked with raised incidence of hypertension and atherogenic lipid profile. Obese people may face abnormal pulmonary function. In obesity the chest wall compliance diminishes, respiratory reserve volume and vital capacity also decreases. This leads to ventilation perfusion mismatch and hypoxemia. Severe obesity may lead to hypoventilation or the Pickwickian syndrome. Sleep apnea and bronchial asthma are the most common and severe disorders.

 

It leads to adverse metabolic effects on cholesterol, triglycerides, pulmonary and systemic vascular compliance in addition to chronic musculoskeletal problems and infertility.

 

Obesity when combined with diabetes significantly accelerates aging problem. Obesity along with hyperglycemia magnifies the risk for dementia. There is an increase in tendency towards depression and suicide among obese people. Obesity also enhances the biliary secretion of cholesterol resulting in higher incidence of gallstone of cholesterol variety. Obesity poses high chances of cancers of liver, stomach, kidney, breast, prostate, uterine and cervix than the non-obese individuals. Obesity has evolved as a drastic threat to public health. It is associated with substantial increase in morbidity resulting from a wide range of co-morbid diseases leading to an increased risk for premature death. It also hampers the psychological wellbeing and overall quality of life. Obesity therefore, simultaneously acts as an independent risk factor for the onset of all these health problems.

 

3.2 Psychosocial impacts

 

The effects of obesity are not limited to physical health. Obese individuals have to deal with damaging effects of societal bias towards excess weight. Weight bias refers to the negative stereotypes about, and unfair attitudes toward those who are overweight or obese. These attitudes can translate into negative behavior towards them, including derogatory comments, teasing and bullying, and exclusion from social events or groups. No one is immune from implicit negative attitudes toward overweight or obese condition. Weight bias could be experienced at workplace, social events, or even at home or among family gatherings.

 

Individuals who are subjected to such bias may get involve in unhealthy weight-loss practices or disordered eating behaviors. Such victims also suffer from lower self esteem and are likely to undergo depression. Not only this, such people tend to develop tendencies for suicide, as they have reduced stress tolerance.

 

Summary

 

Obesity has gained epidemic nature. Its association with an extensive range of health risks is a global concern. It is paving way for a high risk future health and social problems. Developing nations encounter an ironic condition where obesity and undernutrition are coexisting requiring diverse strategies to combat their health related problems. The emerging global economy has led to the shift from traditional diets and physical activity patterns to modern, calorie-dense diets and sedentary lifestyles. Because of this change, overweight/obesity is evident in all countries across the world, regardless of their economic status or ethnic makeup. It results in serious physical and psychological consequences that must be addressed promptly and efficiently. Interventions must be done whereby healthy dietary habits, behavioral modification and adequate physical activity should be the main targets.

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    Suggested Readings

  • Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive summary of the third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III). JAMA. 2001. 285:2486-97.
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  • World Health Organization. Global strategy on diet, physical activity and health. www.who.int/dietphysicalactivity/publications/facts/obesity/
  • National Heart, Lung, and Blood Institute. The practical guide: identification, evaluation, and treatment of overweight and obesity in adults. 2000. www.nhlbi.nih.gov/guidelines/obesity/practgde.htm
  • WHO Expert Consultation. 2004. Appropriate body mass index for Asian populations and its implications for policy and intervention strategies. Lancet. 363:157-63.