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 Table of Contents  
REVIEW ARTICLE
Year : 2018  |  Volume : 5  |  Issue : 3  |  Page : 117-127

Emerging and current trend in the investigation of obesity in clinical practice


1 Department of Pharmacology and Therapeutics, University of Medical Sciences, Ondo City, Ondo State, Nigeria
2 Department of Internal Medicine, Irruar Specialist Teaching Hospital, Irruar, Edo State, Nigeria
3 Department of Family Medicine, University of Medical Sciences, Ondo City, Ondo State, Nigeria
4 Department of Hematology, University of Medical Sciences, Ondo City, Ondo State, Nigeria
5 Department of Radiology, Trauma Surgical Center and University of Medical Sciences, Ondo City, Ondo State, Nigeria

Date of Submission15-Mar-2018
Date of Acceptance13-Aug-2018
Date of Web Publication24-Dec-2018

Correspondence Address:
Dr. Olumuyiwa John Fasipe
Department of Pharmacology and Therapeutics, Faculty of Basic Clinical Sciences, University of Medical Sciences, Ondo City, Ondo State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jhrr.jhrr_15_18

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  Abstract 

Obesity is a medical condition in which excess body fat has accumulated to the extent that it could produce a negative adverse health effect. The various emerging and current investigational methods or techniques for the analysis and determination of total body fat composition and body fat percentage are the theoretical gold standard method of underwater weighing which has its foundation on Archimedes' principle, Bioelectrical Impedance Analysis (BIA), Whole-body Air Displacement Plethysmography (ADP), Dual-Energy X-ray Absorptiometry (DEXA), Near Infrared interactance (NIR), Body Average Density (BAD) Measurement, Ultrasound Sonography Technique (UST) and Anthropometric Measurements (AM) such as triceps skinfold thickness (TSF), Mid-upper arm circumference (MAC), Body Mass Index (BMI), Waist Circumference (WC), Waist-to-Hip Ratio (WHR), Waist-to-Stature ratio (WSR or WHtR), Waist-to-thigh ratio (WTR) and/or Obesity Determinant Indices (ODI). We the authors of this research work currently propose and recommend the Obesity Determinant Indices (ODI) as novel anthropometric measurements that will serve as a more reliable predictor and accurate indicator of cardiovascular disease risk factors, including body fat redistribution, hypertension, dyslipidemia, stroke, ischemic heart diseases, heart failure, chronic kidney disease, sleep apnea and type 2 diabetes mellitus in obese patients. Furthermore, We also jointly propose and recommend the diagnostic and interventional criteria for obesity treatment which are the First Criteria (Criteria-I) and Second Criteria (Criteria-II). These criteria take into consideration the presence of an individual body mass index (BMI), presence of at least one waist circumference (WC) dependent parameters (such as WC or WHR or WHtR or WTR or any of the ODI) that fall into the obesity reference range, and/or presence of at least one obesity-related comorbid conditions/risk factors such as hypertension, type 2 diabetes mellitus, dyslipidemia, osteoarthritis, rheumatoid arthritis, polycystic ovarian syndrome, heart failure, ischemic heart diseases, sleep apnea, depression disorders, anorexia nervosa, bulimia nervosa or any other obesity-associated neuropsychiatric disorders. In conclusion, initiation of appropriate treatment in the form of High-Intensity Lifestyle Interventions alone or a combination of pharmacotherapy with Low-to-Moderate-Intensity Lifestyle Interventions should be commenced for any patient that meet these stipulated criteria guidelines.

Keywords: Clinical practice, current trend, emerging, investigation, obesity determinant indices, proposed obesity diagnostic and interventional criteria


How to cite this article:
Fasipe OJ, Akhideno PE, Adelosoye AA, Osho PO, Ibiyemi-Fasipe OB, Osho ES. Emerging and current trend in the investigation of obesity in clinical practice. J Health Res Rev 2018;5:117-27

How to cite this URL:
Fasipe OJ, Akhideno PE, Adelosoye AA, Osho PO, Ibiyemi-Fasipe OB, Osho ES. Emerging and current trend in the investigation of obesity in clinical practice. J Health Res Rev [serial online] 2018 [cited 2019 May 19];5:117-27. Available from: http://www.jhrr.org/text.asp?2018/5/3/117/248442


  Introduction Top


Obesity is a medical condition in which excess body fat has accumulated to the extent that it could produce a negative adverse health effect.[1] It is usually defined by body mass index (BMI) and further evaluated in terms of body fat distribution.[1],[2] BMI is closely related to both body fat percentage (BFP) and total body fat composition.[2] In children and adults, a healthy weight varies with age and sex. Obesity in children and adolescents is defined not by an absolute number but in relation to a historical normal group-match for age and sex, such that obesity is a BMI >95th percentile.[2],[3] The reference data on which these percentiles were based date from 1963 to 1994, and thus have not been affected by the recent increases in weight.[4]

Epidemiology

Obesity is a leading preventable cause of death worldwide, with increasing rates in adults and children.[1],[5] The global prevalence of overweight and obesity has dramatically increased since 1980 when the average proportion of adults with a BMI of 25 kg/m2 was estimated at 28%.[2] The latest WHO statistics indicate that approximately 39% (1.9 billion) of adults above the age of 18 years are overweight and 13% (603.7 million) are classified as obese.[1] Supporting the trend in increase, it has been estimated that by the year 2025, this figure will have risen to 3 billion people being overweight, and nearly 700 million being obese. The incidence of obesity in children is also on the increase, with estimated new cases of about 42 million children worldwide being affected. Many studies have shown the increase in risk for obese and overweight individuals to develop diabetes mellitus (DM),[3] cardiovascular diseases (CVDs),[4] certain type of cancers (such as endometrial carcinoma), polycystic ovarian syndrome (PCOS),[6] musculoskeletal disorders,[7] endocrine disorders[8] and psychiatric disorders.[9] Obesity is responsible for 3.4 million global deaths annually and accounts for about 4% of life lost per year. It can, therefore, be classified as a pandemic ravaging both developed and developing nations globally.[2] At the international level, in 2015 among the 20 most populous countries, the highest level of age-standardized adult obesity was observed in Egypt (35.3%; 95% uncertainty interval, 33.6–37.1), and the highest level of age-standardized childhood obesity was observed in the United States (12.7%; 95% uncertainty interval, 12.2–13.2). The prevalence was lowest among adults in Vietnam (1.6%; 95% uncertainty interval, 1.4–2.0) and children in Bangladesh (1.2%; 95% uncertainty interval, 0.9–1.7). Between 1980 and 2015, the age-standardized prevalence of obesity increased by a factor of 2 or more in 13 of the 20 countries; only the Democratic Republic of Congo had no increase. In 2015, China and India had the highest numbers of obese children, whereas the United States and China had the highest numbers of obese adults.[2],[10] In 2013, the American Medical Association classified obesity as a disease.[11],[12] Obesity is associated with increased risk of many physical and mental disease conditions, particularly CVDs, type 2 DM, obstructive sleep apnea, certain type of cancers (such as endometrial carcinoma), osteoarthritis,[2] asthma, infertility (due to PCOS), and depression disorders.[2],[13] As a result, obesity has been found to reduce life expectancy significantly.[2] Obesity predisposes affected individuals to metabolic syndrome; a combination of medical disorders which includes:type 2 DM, hypertension, and hyperlipidemias. Once considered a problem only of high-income countries, obesity rates are raising worldwide and affecting both the developed and developing world.[7],[8],[9] These increases have been felt most dramatically in urban settings.[14] The only remaining region of the world where obesity is not common is sub-Saharan Africa, but gradually the reverse is coming into play as a sedentary lifestyle is on the increase.[15]

Determination of total body fat composition and body fat percentage

BFP is the total weight of estimated body fat divided by total body weight expressed as a percentage. Body fat includes essential body fat and storage body fat. Essential body fat is necessary to maintain life and reproductive functions. The percentage of essential body fat for women is greater than that for men, due to the demands of childbearing and other hormonal functions. The percentage of essential body fat is 2%–5% in men, and 10%–13% in women.[6],[7],[8],[15] Storage body fat consists of fat accumulation in adipose tissue, part of which protects internal organs in the chest and abdomen. The minimum recommended total BFP exceeds the essential body fat percentage value reported above. For women, BFP value within the range of 26%–31%; 32%–39%; and ≥40% are regarded as normal; overweight; and obese, respectively. While for men, BFP values within the range of 18%–22%; 23%–29%; and ≥30% are regarded as normal; overweight; and obese, respectively. The BFP is a measure of the fitness level of an individual since it is the only body measurement which directly calculates a person's relative body composition without regard to height or weight. [Figure 1] shows brief illustrations regarding the various types of adipocytes. [Figure 2] reveals the weight loss at 1 year with high-intensity lifestyle interventions or pharmacotherapy combined with low-to-moderate intensity lifestyle counseling. While [Table 1] shows the recommended components of a high-intensity comprehensive lifestyle intervention to achieve and maintain a 5%–10% reduction in body weight for the obese patient within a year of treatment. Finally, the Proposed Edmonton Clinical and Functional Obesity Staging System showed in [Table 2] is a classification system that captures the presence of obesity weight-related comorbidities and risk factors. It classifies individuals on a five-point ordinal scale based on the presence and severity of mental, medical, and functional complications of excess weight and proves to be a better predictor of mortality than BMI, waist circumference (WC), or metabolic syndrome. The Edmonton Clinical and Functional Obesity Staging System has now been included in clinical practice recommendations by the American Society of Bariatric Physicians and by the Canadian Obesity Network. The various emerging and current investigational methods or techniques for the analysis and determination of total body fat composition and BFP are enumerated as follows:[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34],[35],[36],[37],[38],[39],[40],[41]
Figure 1: Showing brief illustrations regarding the various types of Adipocytes

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Figure 2: Weight Loss at 1 year with high-intensity lifestyle interventions or pharmacotherapy combined with low-to-moderate-intensity lifestyle counseling. Shown are the percentages of participants in randomized, controlled trials who had weight loss of at least 5% or at least 10% of their initial weight at 1 year after a high intensity lifestyle intervention or pharmacotherapy that typically was combined with low-to-moderate-lifestyle intervention Counseling (≤1 session per month). Percentages shown are cumulative; the percentage of participants who lost at least 5% of their initial weight includes the percentages who lost at least 10%. For example, 68% of participants in the look AHEAD study lost at least 5% of their initial weight, and 37% of these participants lost at least 10%. The lifestyle interventions trials (Look AHEAD,[3] the Diabetes Prevention Program trial,[17] and the trial reported by Teixeira et al.[3],[17]) were selected because they were judged to be of fair or good quality by the Guidelines (2013) for the Management of Overweight and Obesity in Adults[5] and because the trial data are reported as categorical weight losses. Additional categorical weight-loss from the Diabetes Prevention Program trial[17] were provided by the Diabetes Prevention Program Research Group. The median percentages of participants who had a weight loss of at least 5% or 10% with each of five medications approved for long-term weight management are from a meta-analysis by Khere et al.[3],[5],[17] Data on the percentages of participants with weight loss at 1 year of at least 15% of their initial weight were available for the look AHEAD study[3],[8] (16%), the Diabetes Prevention Program trial[17] (11%), liraglutide[19] (14%), phentermine–topiramate[20] (32%), and naltrexone–bupropion[21] (14%)

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Table 1: Recommended components of a high-intensity comprehensive lifestyle intervention to archive and maintain a 5%–10% reduction in body weight*

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Table 2: Proposed clinical and functional staging of obesity

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Gold standard method of underwater weighing

Out of the several methods of determining the body's fat composition, the most accurate determination method is still the “theoretical gold standard method of underwater weighing,” has its foundation on Archimedes' principle dating back to 250BC: “The buoyant force which water exerts on an immersed object is equal to the weight of water that the object displaces.”[5],[14],[15],[16],[17] Total body fat can, therefore, be calculated by completely submerging a person in water and measuring the weight (volume) of displacement. Fat-free mass has a density of 1.1 kg/L (consisting of 72% water (density = 0.993), 21% protein (density = 1.340), and 7% minerals (density = 3.000) by weight), where fatty tissues in humans body are composed almost entirely of pure triglycerides with an average density of about 0.9 kg/L. Ignoring the presence of air and contents in the lungs and gastrointestinal tract, it can then be calculated that if a person weighs 100 kg, he will displace 95 L of water if he has a fat percentage of 50%. This is obviously impractical to perform in the clinical setup; thus, a lack of an acceptable golden standard has led to various methods attempting to measure and calculate body fat. Each method has limitations, and therefore practitioners need to have adequate knowledge of these measuring techniques to make an accurate assessment.[10],[11],[12],[19],[20],[21]

Bioelectrical impedance analysis

Bioelectrical Impedance Analysis (BIA) employs the principle of electrical impedance or resistance to the flow of an electric current through the different body tissues. An algorithm is used to calculate total body water and fat-free body mass, which is subtracted from the total body mass to give an estimated total body fat.[17] BIA devices are commercially available and frequently used due to the low cost, portability, and noninvasiveness of this procedure. Several factors may affect the accuracy of the reading, such as hydration status, exercise, ambient temperature, position of electrode placement, and equipment calibration. The over and underestimation of body fat by using BIA ranges between 7% and 14%.[5]

Whole-body air displacement plethysmography

Whole-body air displacement plethysmography (ADP) is a recognized and scientifically validated densitometric method to measure human BFP.[6] ADP uses the same principles as the gold-standard method of underwater weighing but representing a densitometric method that is based on air displacement rather than on water immersion. Air-displacement plethysmography offers several advantages over established reference methods, including a quick, comfortable, automated, noninvasive, and safe measurement process, and accommodation of various subject types (e.g., children, obese, elderly, and disabled persons).[7] However, its accuracy declines at the extremes of BFP values, tending to slightly underestimate the percentage body fat in overweight and obese persons (by 1.68%–2.94% depending on the method of calculation), and to overestimate to a much larger degree the percentage body fat in very lean subjects (by an average of 6.8%, with up to a 13% overestimation of the reported body percentage of one individual, i.e., 2% body fat by Dual-Energy X-ray Absorptiometry (DEXA) but 15% by ADP).[8]

Dual-energy X-ray absorptiometry

The use of dual-energy X-ray absorptiometry (DEXA) has recently been advocated as a possible golden standard in determining body composition. Here an energy source produces photons at different energy levels, which are measured and used to differentiate between nonidentical elemental profiles such as fat, bone, and muscle. Body fat can accurately be calculated, but the high costs involved make it an unlikely tool to be used in everyday practice. The instruments also have a maximum capacity of approximately 180 kg, thus morbidly obese patients would not enjoy any benefit.[18]

Near-infrared interactance

Near-infrared interactance (NIR) is a relatively new technique used to measure body composition. It is based on the varying degrees of infra-red light absorption by different tissues. It employs computerized spectrophotometer with a single, rapid scanning monochromatic, and fiber optic probe. A beam of infra-red light is transmitted into a biceps. The light is reflected from the underlying muscle and absorbed by the fat. The method is safe, simple, noninvasive, rapid and easy to carry out within a few seconds. It is not affected by body fluid status.[9]

Body average density measurement

Before the adoption of DEXA, the most accurate method of estimating BFP was to measure that person's body average density (BAD) (total mass divided by total volume) and apply a formula to convert that to BFP. Since fat tissue has a lower density than muscles and bones, it is possible to estimate the fat content. This estimate is distorted by the fact that muscles and bones have different densities: for a person with a more than average amount of bone mass, the estimate will be too low. However, this method gives highly reproducible results for individual persons (±1%). The BFP is commonly calculated from one of two formulas (ρ represents body average density (BAD) measurement in g/cm3):

  • Brozek formula: BFP = (4.57/ρ −4.142) ×100
  • Siri formula: BFP = (4.95/ρ −4.50) ×100


Ultrasound Sonography Technique

Ultrasound Sonography Technique (UST) is used extensively to measure tissue structure and has proven to be an accurate technique to measure subcutaneous fat thickness.[11] A-mode and B-mode ultrasound systems are now used, and both rely on using tabulated values of tissue sound speed and automated signal analysis to determine fat thickness. By making thickness measurements at multiple sites on the body, you can calculate the estimated BFP.[12],[19] Ultrasound techniques can also be used to directly measure muscle thickness and quantify intramuscular fat. Ultrasound equipment is expensive, and not cost-effective solely for body fat measurement, but where equipment is available, as in hospitals, the extra cost for the capability to measure body fat is minimal.[17]

Mid-upper arm anthropometric measurements

Measuring triceps skinfold thickness (TSF) and mid-upper arm circumference (MAC) are noninvasive, inexpensive, and easy to perform. From these two measurements, the mid-upper arm muscle circumference (MAMC) can be calculated: [MAMC = MAC − (3.142×TSF)]. The determined value is then compared to standardized age and gender reference ranges. A value below the fifth percentile demonstrates underweight, whereas a value above the 95th percentile implies obesity.[10] The mid-upper arm muscle area (MAMA) = {[MAMC]2/9.425}. The mid-upper arm anthropometric measurements are more useful in monitoring long-term nutritional therapy in malnourished children than assessing obesity in adults. Using this method may under-or overestimate body composition by up to 10% in severely obese individuals.[11]

Body mass index

Body mass index (BMI) also known as Quetelet index is calculated by dividing the body weight by the square of the body height (kg/m2). It is easy to perform and is the most widely used clinical tool in the indirect assessment of obesity. A typical BMI representing a normal weight range is between 18.5 and 24.9 kg/m2. Values <18.5 are considered underweight whereas a value above 30 is classified as obese. Overweight represents values between 25 and 29.9.[1] Although the definition and grading of obesity by the WHO make use of the BMI scale, it has serious limitations. Omitted variables such as age (body fat physiologically increases with age), sex (females inevitably have a higher body fat composition), fat distribution, muscle mass and bone structure (athletes or body builders with high muscle mass and lower body fat), may result in an individual being misclassified due to either overestimation or underestimation of body fat.[4],[12] Some studies suggest that if the calculated BMI has to be compared to BIA, the overestimation of obesity could be as high as 30%–60%.[19]

Body fat may be estimated from the BMI by formulae derived by Deurenberg et al. When making calculations, the relationship between densitometrically determined BFP and BMI must take age and sex into account. Internal and external cross-validation of the prediction formulas showed that they gave valid estimates of body fat in males and females at all ages. In obese subjects, however, the prediction formulas slightly overestimated the BFP. The prediction error is comparable to the prediction error obtained with other methods of estimating BFP, such as skinfold thickness measurements and bioelectrical impedance. The formula for children is different; the relationship between BMI and BFP in children was found to differ from that in adults due to the height-related increase in BMI in children.[16]

  • Child BFP = (1.51 × BMI) − (0.70 × Age) − (3.6 × sex value) + 1.4
  • Adult BFP = (1.20 × BMI) + (0.23 × Age) − (10.8 × sex value) − 5.4


Where the sex value substitute is one for males; and zero for females in the above-stated equations.

Waist circumference

Determining the waist circumference (WC) is another tool for classifying obesity with regards to the cardiovascular risk profile. WC measurement is useful in patients who are categorized as normal or overweight on the BMI scale (≤30 kg/m2). Men are classified as “high risk” if the horizontally measured circumference at the midpoint of the distance between the lower margin of the last palpable rib and the top of the iliac crest exceeds 102 cm using a stretch-resistant tape that provides a constant 100 g tension. For nonpregnant women, the threshold should not exceed 88 cm. A higher than these threshold values for the specified sex is considered to imply a high risk for type 2 diabetes, dyslipidemia, hypertension, and CVD. Measuring circumference at the level of umbilicus may underestimate the true WC.[20] Measuring the WC only alludes to the location of fat, but not the absolute percentage of body fat. Using this method has an error rate of approximately 3%. Waist-to-hip circumference ratio has also been used, and has been found to exhibit better accuracy, reliability and validity than WC alone, but more complicated to measure.[19],[21] WC can be a better indicator of obesity-related disease risk than BMI, for example, this is the case in populations of Asian descent and older people.

Hip circumference

The Hip circumference should be horizontally measured around the widest portion of the buttocks taking into consideration both the left and right lateral iliac crests (or anteriorsuperior iliac spines) as landmark, with the stretch-resistant tape parallel to the floor. For either HC or WC measurements, the individual should stand with feet close together, arms at the side and body weight evenly distributed, and should wear little clothing. The subject should be relaxed, and the measurements should be taken at the end of a normal respiration. Each measurement should be repeated twice; if the measurements are within 1 cm of one another, the average should be calculated. If the difference between the two measurements exceeds 1 cm, the two measurements should be repeated.[13],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30]

Waist-hip ratio

Waist-hip ratio or waist-to-hip ratio (WHR) is the dimensionless ratio of the circumference of the waist to that of the hips. This is calculated as waist measurement divided by hip measurement (WC/HC). WHR is used as a measurement of obesity, which in turn is a possible indicator of other more serious health conditions. The WHO states that abdominal obesity is defined as a WHR above 0.90 for males and above 0.85 for females. Men or women with WHR values more than these specified thresholds are at increased health risk due to their fat distribution. WHR has been found to be a more efficient predictor of mortality in older people (>75 years of age) than WC or BMI.[9] If obesity is redefined using WHR instead of BMI, the proportion of people categorized as at risk of heart attack worldwide increases threefold.[14] The BFP is considered to be an even more accurate measure of relative weight. Of these three measurements, only the WHR takes account of the differences in body structure. Hence, it is possible for two women to have vastly different body mass indices but the same WHR, or to have the same BMI but vastly different WHRs. WHR has been shown to be a better predictor of CVD than WC or BMI alone.[15] However, other studies have found WC, not WHR, to be a good indicator of cardiovascular risk factors, body fat distribution, and hypertension in type 2 diabetes.[5],[16],[17] In fact, it is more pragmatic to say that “Hip size indicates pelvic size and the amount of additional fat storage that can be used as a source of energy while the waist size conveys information such as current reproductive status or health status. In westernized societies with no risk of seasonal lack of food, the waist size, conveying information about fecundity and health status, and will be more important than hip size for assessing a female's attractiveness.”[13],[31],[32],[33],[34],[35]

Waist-to-height ratio or waist-to-stature ratio

Waist-to-height ratio (WHtR), also called waist-to-stature ratio (WSR) is estimated using the body WC divided by the body height. The values indicating increased obesity risk are: >0.50 for people under 40 years of age, >0.55 for people aged 40–50, and >0.60 for people over 50 years of age. A 2010 study that followed 11,000 subjects for up to eight years concluded that WHtR is a much better measure of the risk of heart attack, stroke or death than the more widely used BMI.[2] However, a 2011 study that followed 60,000 participants for up to 13 years found that WHR (when adjusted for BMI) was a better predictor of ischemic heart disease mortality than WHtR.[34],[35],[36],[37],[38],[39],[40]

Waist-thigh ratio

Waist-thigh ratio or waist-to-thigh ratio (WTR) is another recently discovered new anthropometric measurement and tool that is being used as one of the important markers for diagnosing obesity and to predict high risk of developing type 2 DM. It is defined as the ratio of the WC to the thigh circumference (TC); that means WC/TC. TC has been recognized recently as a relevant anthropometric measure that identifies individuals with increased risk of premature morbidity and mortality from CVDs early in the disease. Strong correlations with obesity, fasting, random, and 2 h-postprandial plasma glucose level have been demonstrated. Insulin resistance syndrome and obesity are associated with excessive visceral abdominal fat. Recent evidence links low subcutaneous fat, especially in the thighs, with adverse glucose and lipid metabolism. Insulin resistance also depends on muscle mass. Less muscle mass, especially in the lower extremity, is inversely related to the development of type 2 DM and obesity. A thin thigh with low TC and low muscle mass and a greater WTR predicts obesity and increase the risk for type 2 DM.

According to the WHO standard, the TC should be measured when the individual patient is standing upright with both feet close together, both arms at the side and body weight evenly distributed, and should be wearing little clothing. The patient right thigh clothing is minimally exposed to the hip region when about to take the TC measurement. TC is measured horizontally at the level of the midpoint located on the lateral surface of the right thigh, midway between the greater trochanter of the right femur and the upper lateral border of the head of the right tibia using a standard flexible inelastic measuring tape and the patient should also be relaxed. Each measurement should be repeated twice; if the measurements are within 1 cm of one another, the average should be calculated. If the difference between the two measurements exceeds 1 cm, the two measurements should be repeated. In a research done by Kumar et al. (2018);[41] WTR correlates significantly and positively with obesity and to all the three measures of type 2 DM namely fasting plasma glucose (FPG), random plasma glucose (RPG), and 2 h-postprandial plasma glucose (2 h-PPG) [P < 0.0001]. While TC has a strong negative correlations with obesity and to all the three measures of type 2 DM namely FPG, RPG, and 2 h-PPG (P < 0.0001). Compared to WHR; WTR has a higher correlations with obesity and to all the three measures of type 2 DM (FPG, RPG, and 2 h-PPG), suggesting that it is a statistically more powerful and better predictor of obesity and type 2 DM. Furthermore, in the Kumar et al.[41] study, a WTR value of 2.3 was found to identify 98.7% of the true negatives (degree of specificity), and this WTR value of 2.3 was proposed to be used as the cut-off point for obesity diagnosis and better predictor of increased risk for type 2 DM. However, there is need to carry out a much larger and varied sample research to develop a more robust and stable standard reference range that would make this measurement more reliable across age- and sex-match groups in addition to a well define separate criteria for males and females.[37],[38],[39],[40],[41]

Obesity Determinant Indices

We the authors of this research work currently propose and recommend the obesity determinant indices (ODI) as novel anthropometric measurements that will serve as a more reliable predictor and accurate indicator of cardiovascular disease risk factors, including body fat redistribution, hypertension, dyslipidemia, stroke, ischemic heart diseases, heart failure, chronic kidney disease, sleep apnea and type 2 diabetes mellitus in obese patients. These proposed obesity determinant indices (ODI) are ODIHC, ODIHt and ODITC which take into consideration an inverse dependent relationship involving the hip circumference (HC), height (Ht) and thigh circumference (TC) respectively. Each of the ODI calculations takes into consideration four independent parameters which are the weight, height, waist circumference and any one of either hip circumference or height or thigh circumference.

The ODIHC for an individual is defined as the product of the body mass index (BMI) and the waist-to-hip ratio (WHR). Mathematically expressed as ODIHC= BMI×WHR. Using the WHO recommended values for these parameters, the ODIHC thresholds for obesity in men and women are 27 kg/m2 and 25.5 kg/m2 respectively. Any ODIHC value greater than these sex or gender-specified thresholds are regarded as obesity because of the associated negative health risks produced by body fat redistribution.

The ODIHt for an individual is defined as the product of the body mass index (BMI) and the waist-to-height ratio (WHtR). Mathematically expressed as ODIHt= BMI×WHtR. Using the recommended values for these parameters, the ODIHt thresholds for obesity is 15 kg/m2 for people under 40 years of age, 16.5 kg/m2 for people aged 40–50 years, and 18 kg/m2 for people over 50 years of age. Any ODIHt value greater than these age-specified thresholds are regarded as obesity because of the associated negative health risks produced by body fat redistribution.

The ODITC for an individual is defined as the product of the body mass index (BMI) and the waist-to-thigh ratio (WTR). Mathematically expressed as ODITC= BMI×WTR. According to the research done by Kumar, et al.[41] (2018); a WTR value of 2.3 was found to identify 98.7% of the true negatives (degree of specificity) and this WTR value of 2.3 was proposed to be used as the cut-off point for obesity diagnosis and better predictor of increased risk for obesity related or associated cardiovascular disorders.[41] Using the recommended values for these parameters, the ODITC threshold for obesity is 69 kg/m2. Any ODITC value greater than this specified threshold is regarded as obesity because of the associated negative health risks produced by body fat redistribution. However, there is a need to carry out a much larger and varied sample research in order to develop a more robust and stable standard reference value for ODITC that would make this measurement more reliable across age- and sex-match groups in addition to a well define separate criteria for men and women.[1],[8],[9],[10],[11],[12],[13],[34],[35],[36],[37],[38],[39],[40],[41]

Proposed Obesity Diagnostic and Interventional Criteria

We the authors of this research work jointly propose and recommend the following diagnostic and interventional criteria for obesity treatment which are the First Criteria (Criteria-I) and Second Criteria (Criteria-II). These criteria take into consideration the presence of an individual body mass index (BMI), presence of at least one waist circumference (WC) dependent parameters (such as WC or WHR or WHtR or WTR or any of the ODI) that fall into the obesity reference range, and/or presence of at least one obesity-related comorbid conditions/risk factors such as hypertension, type 2 diabetes mellitus, dyslipidemia, osteoarthritis, rheumatoid arthritis, polycystic ovarian syndrome, heart failure, ischemic heart diseases, sleep apnea, depression disorders, anorexia nervosa, bulimia nervosa or any other obesity-associated neuropsychiatric disorders.

First criteria (criteria-I)

  1. Presence of Overweight BMI category (25 kg/m2 − 29.99 kg/m2), with the presence of both (b) and (c) listed below.
  2. Presence of at least one waist circumference dependent parameters (such as WC or WHR or WHtR or WTR or any of the ODI) that fall into the obesity reference range, and
  3. Presence of at least one obesity-related comorbid conditions/risk factors such as hypertension, type 2 diabetes mellitus, dyslipidemia, osteoarthritis, rheumatoid arthritis, polycystic ovarian syndrome, heart failure, ischemic heart diseases, sleep apnea, depression disorders, anorexia nervosa, bulimia nervosa or any other obesity-associated neuropsychiatric disorders.


Second criteria (criteria-II)

  1. Presence of Obese BMI category (≥30 kg/m2), with the presence of either (b) or (c) listed below.
  2. Presence of at least one waist circumference dependent parameters (such as WC or WHR or WHtR or WTR or any of the ODI) that fall into the obesity reference range, or
  3. Presence of at least one obesity-related comorbid conditions/risk factors such as hypertension, type 2 diabetes mellitus, dyslipidemia, osteoarthritis, rheumatoid arthritis, polycystic ovarian syndrome, heart failure, ischemic heart diseases, sleep apnea, depression disorders, anorexia nervosa, bulimia nervosa or any other obesity-associated neuropsychiatric disorders.


In summary, initiation of appropriate treatment in the form of High-Intensity Lifestyle Interventions alone or a combination of pharmacotherapy with Low-to-Moderate-Intensity Lifestyle Interventions should be commenced for any patient that meet these stipulated criteria guidelines.[42] Life style modification interventions include diet with low sodium salt content, diet high in polyunsaturated fat and low in saturated fat, low carbohydrate diet intake, no smoking, increase potassium intake from fruits and vegetables, low alcohol intake, adequate protein and micronutrients intake with increase aerobic exercise for those in overweight or obesity range.[42] Bariatric surgery is the most effective treatment for obesity when the other form of interventions have failed to produce a clinically significant weight loss in individuals with BMI of ≥ 40kg/m2 alone, or individuals with BMI of ≥ 35kg/m2 and at least one associated complicating risk factors such as hypertension, type 2 diabetes mellitus, dyslipidemia, osteoarthritis, rheumatoid arthritis, polycystic ovarian syndrome, heart failure, ischemic heart diseases, sleep apnea, depression disorders, anorexia nervosa, bulimia nervosa or any other obesity-associated neuropsychiatric disorders.[21],[42] The types of procedures include laparoscopic adjustable gastric banding, Roux-en-Y gastric bypass, vertical-sleeve gastrectomy, and biliopancreatic diversion.[4],[42] Surgery for severe obesity is associated with long-term weight loss, improvement in obesity related conditions,[5],[12],[13],[14],[15],[16],[42] and decreased overall mortality. One study found a weight loss of between 14% and 25% (depending on the type of procedure performed) at 10 years, and a 29% reduction in all causes of mortality when compared to standard weight loss measures.[6],[42] Complications occur in about 17% of cases and reoperation is needed in 7% of cases.[7],[15],[16],[17],[18],[19],[42] Due to its high cost and risks, researchers are searching for other effective yet less invasive treatments including devices that can occupy space in the stomach.[8],[20],[42]


  Conclusion Top


The incidence and prevalence of obesity are on the increase worldwide. The cost burden and negative impacts on the health-care system are tremendously alarming. Clinically significant weight loss attenuates the risk of CVD morbidity and mortality. Prevention is an important part of dealing with any disease including obesity. The various emerging and current investigational methods or techniques for the analysis and determination of total body fat composition and BFP are the theoretical gold standard method of underwater weighing which has its foundation on Archimedes' principle, BIA, whole-body ADP, DEXA, NIR, BAD measurement, UST, and anthropometric measurements (AM) such as TSF, MAC, BMI, WC, WHR, WSR, WTR and/or ODI. Physicians are advised to use their discretions during the process of selecting the appropriate investigational method(s) for their obese or overweight patients while at the same time considering their cost implications and affordability by those patients in order to achieve a maximum treatment impact in them. We the authors of this research work currently propose and recommend the obesity determinant indices (ODI) as novel anthropometric measurements that will serve as a more reliable predictor and accurate indicator of cardiovascular disease risk factors, including body fat redistribution, hypertension, dyslipidemia, stroke, ischemic heart diseases, heart failure, chronic kidney disease, sleep apnea and type 2 diabetes mellitus in obese patients. Furthermore, We also jointly propose and recommend the diagnostic and interventional criteria for obesity treatment which are the First Criteria (Criteria-I) and Second Criteria (Criteria-II). In conclusion, initiation of appropriate treatment in the form of High-Intensity Lifestyle Interventions alone or a combination of pharmacotherapy with Low-to-Moderate-Intensity Lifestyle Interventions should be commenced for any patient that meet these stipulated criteria guidelines.

What this review adds to the body of knowledge about the pharmacotherapy of obesity

(1) The various emerging and current investigational methods or techniques for the analysis and determination of total body fat composition and BFP are as follows:

  • The theoretical gold standard method of underwater weighing which has its foundation on Archimedes' principle
  • BIA
  • Whole-body ADP
  • DEXA
  • NIR
  • BAD Measurement
  • UST and
  • Anthropometric Measurements (AM) such as TSF, MAC, BMI, WC, WHR, WSR, WTR and/or ODI.


(2) We the authors of this research work currently propose and recommend the obesity determinant indices (ODI) as novel anthropometric measurements that will serve as a more reliable predictor and accurate indicator of cardiovascular disease risk factors, including body fat redistribution, hypertension, dyslipidemia, stroke, ischemic heart diseases, heart failure, chronic kidney disease, sleep apnea and type 2 diabetes mellitus in obese patients. Furthermore, We also jointly propose and recommend the diagnostic and interventional criteria for obesity treatment which are the First Criteria (Criteria-I) and Second Criteria (Criteria-II). In conclusion, initiation of appropriate treatment in the form of High-Intensity Lifestyle Interventions alone or a combination of pharmacotherapy with Low-to-Moderate-Intensity Lifestyle Interventions should be commenced for any patient that meet these stipulated criteria guidelines.

Acknowledgments

The authors of this review want to especially acknowledge and thank the Almighty God for granting them wisdom and understanding to prepare this review for publication.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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