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Definitions, Classification, and Epidemiology of Obesity

, MD.

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Last Update: April 12, 2018.

ABSTRACT

Obesity is now recognized as a chronic or non-communicable disease. Recent research has clarified the physiology of weight regulation, the pathophysiology that leads to unwanted weight gain and maintenance of the obese state even when reasonable attempts in lifestyle improvement are made, and the adverse health consequences of generalized and central obesity. While more sensitive and specific imaging methods to quantify body composition are available, most office-based practitioners will need measure only height, weight, and waist circumference. With these, a patient’s risk for obesity-related co-morbidities such as type 2 diabetes mellitus and cardiovascular disease can be estimated and appropriate treatment plans and goals established. Within the United States, prevalence rates for generalized obesity (BMI > 30 kg/m2), extreme obesity (BMI > 40 kg/m2), and central obesity are continuing to rise with peak obesity rates occurring in the 5th-7thdecades. Women have more generalized obesity but less central obesity than men, and obesity disproportionately affects US minorities. Of concern are increases in obesity rates in youth (ages 2-19 years) in the US as well as around the globe. This trend will likely continue to fuel the global obesity epidemic for decades to come, worsening population health, creating infrastructural challenges as countries attempt to meet the additional health-care demands, and greatly increasing health-care expenditures world-wide. Beyond individual weight management, societal and economic innovations will be necessary that focus on strategies to prevent further increases in overweight and obesity rates. For complete coverage of all related areas of Endocrinology, please visit our on-line FREE web-text, WWW.ENDOTEXT.ORG.

INTRODUCTION

Unwanted weight gain leading to overweight and obesity has become a main driver of the global rise in non-communicable diseases and is itself now considered a non-communicable disease. Because of the psychological and social stigmata that accompany being overweight and obese, those affected by these conditions are also vulnerable to discrimination in their personal and work lives, low self-esteem, and depression. These medical and psychological sequelae of obesity contribute to a major share of current health-care expenditures and generate additional economic costs through loss of worker productivity, increased disability, and premature loss of life.

The recognition that being overweight or obese is a chronic disease and not simply due to poor self-control or a lack of will power comes from the past 70 years of research that has been steadily gaining insight into the physiologythat governs body weight (homeostatic mechanisms involved in sensing and adapting to changes in the body’s internal metabolism, environmental food availability, and activity levels so as to maintain body weight and fat content stability), the pathophysiologythat leads to unwanted weight gain maintenance, and the roles that excess weight and fat maldistribution play in contributing to chronic diseases such as diabetes, dyslipidemia, heart disease, non-alcoholic fatty liver disease, and many others(1, 2).

As with other chronic diseases, obesity results from an interaction between an individual’s genetic predisposition to weight gain and environmental influences. Gene discovery in the field of weight regulation and obesity has identified several major single-gene effects resulting in severe and early-onset obesity as well as many more minor genes with more variable effects on weight and fat distribution, including age-of-onset and severity. However, currently known major and minor genes explain only a small portion of body weight variations in the population(3). Several environmental contributors have also been identifiedbut countering these will likely require initiatives that fall far outside of the discussions taking place in the clinician’s office between patient and provider since they involve making major societal changes regarding food quality, work-related and leisure-time activities, and social determinants including disparities in socio-economic status.

Novel discoveries in fields of neuroendocrine and gastrointestinal control of appetite and energy expenditure have greatly advanced these fields in recent years. These insights have led to an emerging portfolio of medications that, when added to behavioral and lifestyle improvements, can help restore appetite control and allow modest weight loss maintenance. They have also led to novel mechanisms that help to explain the superior outcomes (both in terms of meaningful and sustained weight loss as well as improvements or resolution of co-morbid conditions) following bariatric procedures such as laparoscopic sleeve gastrectomy and gastric bypass(4, 5).

Subsequent chapters in this section of EndoText will delve more deeply into these determinants and scientific advances, providing a greater breadth of information regarding mechanisms, clinical manifestations, treatment options, and prevention strategies for those who are overweight or obese (6-12).

DEFINITION OF OVERWEIGHT AND OBESITY

Overweight and obesity occur when excess fat accumulation (regionally, globally, or both) increases risk to health. It is the point at which health risk is increased that is most important because, as covered below, body weights and fat distributions that lead to expression of co-morbid diseases occur at different thresholds depending on the population.

Ideally, an obesity classification system would have the following characteristics: it would be based on a practical measurement widely available to providers regardless of their setting; it would accurately predict health risk (prognosis); and it could be used to assign treatment stategies and goals. The most accurate measures of body fat (the major component of body weight responsible for adverse outcomes) such as underwater weighing, dual-energy x-ray absorptiometry (DEXA) scanning, computed tomograpy (CT), and magnetic resonance imaging (MRI) are impractical for use in everyday clinical encounters. Estimates of body fat including body mass index (BMI, calculated by dividing the body weight in kilograms by height in meters squared, or kg/m2) and waist circumference do have limitations compared to these imaging methods, but still provide relevant information and are easily implemented in a variety of practice settings.

It is worth pointing out two important caveats regarding thresholds used to diagnose overweight and obesity. The first is that although we favor the assignement of specific BMI cut-offs and increasing risk (Table 1), relationships between body weight or fat distribution and conditions that impair health actually represent a continum. For example, increased risk for type 2 diabetes and premature mortality occur well before a BMI of 30 kg/m2(the threshold to define obesity in popluations of European extraction) is reached. It is in these earlier stages that preventative strategies to limit further weight gain and/or allow weight loss will have their greatest health benefits. The second is that historic relationships between increasing weight thresholds weight and co-morbidities are becoming altered as better treatments for those conditions become available. For example, in the past several decades, atherosclerotic cardiovascular (ASCVD) mortality has steadily declined in the US population (13)even as obesity rates have risen (see below). Although it is generally accepted that this decline in ASCVD deaths is due to better treatments in the field (better coordination of “first responders” services such as ambulances and more widespread use by the public of cardiopulmonary resusitation and defibrillator units), by intensive care units, and in the office (statins, PCSK9 inhibitors, blood pressure medications, stents and other revascularization procedures) (14), these data have also been cited to support of the claim that being overweight might actually protect against heart disease(15). In this regard, updated epidemiological data on the health outcomes related to being overweight or obese should include not just data on morbidity and mortality, but also health care utilization and costs, including medications and number of treatment-related procedures performed.

CLASSIFICATION OF OVERWEIGHT, OBESITY, AND CENTRAL OBESITY

Fat Mass and Percent Body Fat

As mentioned above, fat mass can be directly measured by one of several imaging modalities, including DEXA, CT, and MRI, but these systems are impractical and cost prohibitive for general clinical use and, instead, are mostly used for research. Fat mass can be measured indirectly using water (underwater weighing) or air displacement (BODPOD), or bioimpedance analysis (BIA). Each of these methods estimates the proportion of fat or non-fat mass and allows calcutation of percent body fat. Of these, BODPOD and BIA are often offered through fitness centers and clinics run by obesity medicine specialists. However, their general use in the care of overweight and obese patients is still not recommended. Interpretation of results from these procedures may be confounded by common conditions that accompany obesity, especially when fluid status is altered such as in congenstive heart failure or chronic kidney disease. Also, ranges for normal and abnormal are not well established for these methods and, in practical terms, knowing them will not change current recommendations to help patients achieve sustained weight loss.

Body Mass Index

Body mass index allows comparison of weights independently of stature across populations. Except in persons who have increased lean weight as a result of intense exercise or resistance training (e.g., bodybuilders), BMI correlates well with percentage of body fat, but this relationship is independently influenced by sex, age, and race (16), especially South Asians in whom evidence suggests that BMI-adjusted percent body fat is greater than other populations (17). In the United States, data from the second National Health and Nutrition Examination Survey (NHANES II) were used to define obesity in adults as a BMI of 27.3 kg/m2or more for women and a BMI of 27.8 kg/m2or more for men(18). These definitions were based on the gender-specific 85thpercentile values of BMI for persons 20 to 29 years of age. In 1998, however, the National Institutes of Health (NIH) Expert Panel on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults adopted the World Health Organization (WHO) classification for overweight and obesity (19). The WHO classification, which predominantly applied to people of European ancestry, assigns increasing risk for comorbid conditions—including hypertension, type 2 diabetes mellitus, and cardiovascular disease—to persons with higher a BMI (Table 1) relative to persons of normal weight (BMI of 18.5 - 25 kg/m2). Asian populations, however, are known to be at increased risk for diabetes and hypertension at lower BMI ranges than those for non-Asian groups due to predominance of central fat distribution (see below). Consequently, the WHO has suggested lower cutoff points for consideration of therapeutic intervention in Asians: a BMI of 18.5 to 23 kg/m2represents acceptable risk, 23 to 27.5 kg/m2confers increased risk, and 27.5 kg/m2or higher represents high risk (20).

Table 1

Classification of Overweight and Obesity by BMI, Waist Circumference, and Associated Disease Risk. Adapted from reference (19).

BMI (kg/m2)Obesity ClassDisease Risk* (Relative to Normal Weight and Waist Circumference)
Men ≤40 inches (≤ 102 cm) Women ≤ 35 inches (≤ 88 cm)> 40 in (> 102 cm)
> 35 in (> 88 cm)
Underweight< 18.5--
Normal†18.5–24.9--
Overweight25.0–29.9IncreasedHigh
Obesity30.0–34.9
35.0–39.9
I
II
High
Very High
Very High
Very High
Extreme Obesity≥ 40IIIExtremely HighExtremely High

*Disease risk for type 2 diabetes, hypertension, and cardiovascular disease.

†Increased waist circumference can also be a marker for increased risk even in persons of normal weight.

Fat Distribution (Central Obesity)

In addition to an increase in total body weight, a proportionally greater amount of fat in the abdomen or trunk compared with the hips and lower extremities has been associated with increased risk for type 2 diabetes mellitus, hypertension, and heart disease in both men and women (21, 22). Abdominal obesity is commonly reported as a waist-to-hip ratio, but it is most easily quantified by a single circumferential measurement obtained at the level of the superior iliac crest (19). The original US national guidelines categorized men at increased relative risk for co-morbidities such as diabetes and cardiovascular disease if they have a waist circumference greater than 102 cm (40 inches) and women if their waist circumference exceeds 88 cm (35 inches) (Table 1) (19). Thus, an overweight person with predominantly abdominal fat accumulation would be considered “high” risk for these diseases even if that person is not obese by BMI criteria. These waist circumference thresholds are also used to define the “metabolic syndrome” by the most recent guidelines from the American Heart Association and the National Lipid Association (23, 24).

However, the relationships between central adiposity with co-morbidities are also a continuum and vary by race and ethnicity. For example, in those of Asian descent, abdominal (central) obesity has long been recognized to be a better disease risk predictor, especially for type 2 diabetes, than BMI (25). As endorsed by the International Diabetes Federation (26)and summarized in a WHO report in 2008 (27), different countries and health organizations have adopted differing sex- and population-specific cut off values for waist circumference thresholds predictive of increased risk for weight-related comorbidities. In addition to the US criteria, alternative thresholds for central obesity as measured by waist circumference include >94 cm (37 inches) and >80 cm (31.5 inches) for men and women of European anscestry and >90 cm (35.5 inches) and >80 cm (31.5 inches) for men and women of South Asian, Japanese, and Chinese origin (26, 27).

For the practioner, waist circumference should be measured in a standardized way (19)at each patient’s visit along with body weight. This measurement can be used to identify increased risk for diabetes and cardiovascular disease independent of BMI, which in turn is important for the development of an individualized weight management approach and in motivating patients to adhere to recommended lifestyle and medical therapies. Consideration for the use of lower waist circumference thresholds than those currently recommended in the US should occur when counseling a patient of South and Southeast Asian ancestry or if other components of the metabolic syndrome (e.g., hypertension, elevated fasting glucose (100 – 125 mg/dL; 5.5 – 6.9 mmol/L), dyslipidemia) or prediabetes (hemoglobin A1c between 5.7 and 6.4%) have been identified.

EPIDEMIOLOGY OF OVERWEIGHT AND OBESITY

In the United States (US), data from the National Health and Nutrition Examination Survey using measured heights and weights shows that the steady increase in the prevalence of obesity in both children and adults over the past several decades has not waned, although there are exceptions among subpopulations as described in greater detail below. In the most recently published US report (2015-2016), 39.8% of adults (BMI ≥ 30 kg/m2) and 18.5% of youth (BMI ≥ 95thpercentile of age- and sex-specific growth charts) are obese (28)(Figure 1).

Figure 1. Trends in obesity prevalence among adults aged 20 and over (age adjusted) and youth aged 2–19 years: United States, 1999–2000 through 2015–2016.

Figure 1

Trends in obesity prevalence among adults aged 20 and over (age adjusted) and youth aged 2–19 years: United States, 1999–2000 through 2015–2016. Youth are aged 2019 years and adults are 20 years and older. Taken from reference (28).

Overweight and Obesity in Adults: Relationships with Age, Sex, and Demographics

On average, these increases represent a tripling in obesity prevelance rates of the US population since the 1960’s (Figure 2). Several trends wtihin this data are worth highlighting. During this time, the prevelance of overweight (BMI ≥ 25 and <30 kg/m2) has remained remarkably stable in both men and women while that of extreme obesity (BMI ≥ 40 kg/m2) has undergone a 9-fold increase from 0.9% in 1960-1962 to 8.1% in 2013-14 (Figure 2). These large increases in the number of people with obesity and extreme obesity, while at the same time the level of overweight has remained steady, suggests that the “obesogenic” environment is disproportionately affecting those portions of the population with the greatest genetic potential for weight gain (29, 30). This currently leaves only ~ 30% of the US population as having a healthy weight (BMI between 18.5 and 25 kg/m2).

Figure 2. Trends in adult overweight, obesity, and extreme obesity among men and women aged 20–74: United States, 1960–1962 through 2013–2014.

Figure 2

Trends in adult overweight, obesity, and extreme obesity among men and women aged 20–74: United States, 1960–1962 through 2013–2014. Overweight is body mass index

(BMI) of 25 kg/m2 or greater but less than 30 kg/m2; obesity is BMI greater than or equal to 30; and extreme obesity is BMI greater than or equal to 40. Taken fom (31)

Adult women are, on average, more likely to be obese than men, and the peak rates of obesity for both men and women in the US occur between the ages of 40 and 60 years (Figures 2 and 3). In studies that have measured body composition, fat mass also peaks just past middle age in both men and women, but percent body fat continues to increase past this age, particularly in men because of a proportionally greater loss in lean mass (32-34). The menopausal period has also been associated with an increase in percent body fat and propensity for central fat distribution, even though total body weight may change very little during this time (35-37).

In general, women and men who did not go to college were similarly more likely to be obese than those who did, but for both groups these relationships varied depending on race and ethnicity (see below). Amongst women, obesity prevelance rates decreased with

increasing income in women (from 45.2% to 29.7%), but there was no difference in obesity prevalence between the lowest (31.5%) and highest (32.6%) income groups among men (38).

Figure 3. Prevalence of obesity among adults aged 20 years and over, by sex and age: United States, 2015–2016.

Figure 3

Prevalence of obesity among adults aged 20 years and over, by sex and age: United States, 2015–2016. Taken from reference (28).

Pediatrics

Childhood obesity is a risk factor for adulthood obesity (39, 40). In this regard, the similar tripling of obesity rates in US youth is worrisome. One potential bright spot in the most recent trends is that obesity prevelance rates of the youngest (ages 2-5 years) has shown a leveling off since 2005-2006 (Figure 4 and reference (28)). This may represent societal recognition and reversal of feeding and activity patterns in this age group that have previously promoted weight gain and is an opportune age group (< 6 years of age) in which to reduce the likelihood for continuing a weight trajectory that leads to adult obesity (41). If this remains true, it would still take close to a generation before population rates of obesity in adults are affected. Like adults, obesity rates in children are greater when they are live in households with lower incomes and less education of the head of the household (42). In this regard, these obesity gaps have been steadily widening in girls, whereas the differences between boys has been relatively stable (42).

Minorities

The rise in obesity prevalence rates has disproportionately affected US minority populations (28). The highest prevelance rates of obesity by race and ethnicity are currently reported in blacks, native americans, and Hispanics (Figure 5and reference (43)). Like in the general population, minority women are more affected than men, reaching obesity prevelance rates of 50% and higher for Hispanic and black women. The interactions of socieconomic status and obesity rates varied from the general population based on race and ethnicity (38). For example, the expected inverse relationship between obesity and income group did not hold for non-Hispanic black men and women in whom obesity prevelance was actually higher in the highest compared to lowest income group (men) or showed no relationship to income by racial group at all (women) (38). Obesity prevalence was lower among college graduates than among persons with less education for non-Hispanic white women and men, black women, and Hispanic women, but not for black and Hispanic men. Asian men and women have the lowest obesity prevelance rates, which did not vary by eduction or income level (38).

Figure 4. Trends in obesity among children and adolescents aged 2–19 years, by age: United States, 1963–1965 through 2013–2014.

Figure 4

Trends in obesity among children and adolescents aged 2–19 years, by age: United States, 1963–1965 through 2013–2014. Obesity is defined as body mass index (BMI) greater than or equal to the 95th percentile from the sex-specific BMI-for-age 2000 CDC Growth Charts.

An identical pattern of higher obesity rates to those of adult minority groups (Figure 5) are reported in younger minority populations (28). In those age 2-19 years, the prevalence of obesity is 22% for non-Hispanic black youth, 25.8% for Hispanic youth, 14.1% for non-Hispanic white youth, and 11% for Asian youth (28). Hispanic boys have the highest obesity rates (28%), followed by non-Hispance black girls (25.1%) and Hispanic girls (23.6%) (28). The lowest obesity rates were found in Asian youth. With regard to socieconomic status, the inverse trends for lower obesity rates and higher income and education (of households) held in all race and ethnic origin groups with the following exceptions: obesity prevalence was lower in the highest income group only in Hispanic and Asian boys and did not differ by income among non-Hispanic black girls (42).

Figure 5. Prevalence of obesity among youth aged 2–19 years, by sex and race and Hispanic origin: United States, 2015–2016.

Figure 5

Prevalence of obesity among youth aged 2–19 years, by sex and race and Hispanic origin: United States, 2015–2016. Taken from reference (28).

Central Obesity

As discussed above, central weight distribution occurs more commonly in men than women and increases in both men and women with increasing age. In one of the few datasets that have published time-trends in waist circumference, it has been shown that over the past 20 years, age-adjusted waist circumferences have tracked upward in both US men and women (Figure 6). Much of this likely reflects the population increases in obesity prevelance since increasing fat mass and visceral fat track together (44).

Figure 6. Age-adjusted mean waist circumference among adults in the National Health and Nutrition Examination Survey 1999-2012.

Figure 6

Age-adjusted mean waist circumference among adults in the National Health and Nutrition Examination Survey 1999-2012. Adapted from (45).

Historically, international obesity rates have been lower than in the US and most developing countries considered undernutrition to be their topmost health priority (46). However, international rates of overweight and obesity have been rising steadiy for the past several decades and, in many countries, are now meeting or exceeding those of the US (Figure 7), (47, 48). In 2016, 1.3 billion adults were overweight worldwide and, between 1975 to 2016, the number of adults with obesity increased over six-fold, from 100 million to 671 million (69 to 390 million women, 31 to 281 million men ) (47). Especially worrisome have been similar trends in the youth around the world (Figure 7), from 5 million girls and 6 million boys with obesity in 1975 to 50 million girls and 74 million boys in 2016 (47), as this means the rise in obesity rates will continue for decades as they mature into adults.

Figure 7. Trends in the number of adults, children, and adolescents with obesity and with moderate and severe underweight by region.

Figure 7

Trends in the number of adults, children, and adolescents with obesity and with moderate and severe underweight by region. Children and adolescents were aged 5–19 years. (47).

The growth in the wordwide prelance of overweight and obesity is thought to be primarily driven by economic and technological advancements in all developing societies aroung the globe (49, 50). These forces have been ongoing in the US and other Western countries for many years but are being experienced by many developong countries on a compressed timescale. Greater worker productivity in advancing economies means more time spent in sedentary work (less in manual labor) and less time spent in leisure activity. Greater wealth allows the purchase of televisions, cars, processed foods, and more meals eaten out of the house, all of which have been associated with greater rates of obesity in children and adults. More details and greater discussion of these issues can be found in EndoText Chapters on Non-excercisse Activity Thermogenesis (51)and Obesity and the Environment (52).

Regardless of the causes, these trends in global weight gain and obesity are quickly creating a tremendous burden on health-care systems and cost to countries attempting to respond to the increased treatment demands(53). In addition, they are also feuling a rise in global morbity and mortality for chronic (non-communicable) diseases, especially for cardiovascular disease and type 2 diabetes mellitus, and especially in Asian and South Asian populations where rates of type 2 diabetes are currently exploding (14, 54-57). Efforts need to be made deliver adequate health care to those in need and, at the same time, find innovative and alternative solutions that allow economies to prosper and to incorporate technologies so as to reverse current trends in obesity and obesit-related diseases.

SUMMARY

The general rise in obesity that has been occurring over the past 50 years in the US is now occurring globally. Women have higher obesity rates than men, and in the US, minorities are disproportionately affected compared to non-Hispanic whites, including blacks, native Americans, and Hispanics. Particularly worrisome are similar global trends in the increase in prevalence of obesity in children and adolescents as these groups will continue to contribute to a rising obesity rate in adults for several decades afterward. As important as finding solutions that address the global logistical and financial challenges facing health-care systems attempting to meet current demands of obesity-related co-morbidities will be finding innovative solutions that prevent further weight gain within developing (and developed) countries.

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