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C HAP TE R 38 / Obesity: An Overview of Assessment and Treatment 863

Table 38-1 ■ CLASSIFICATION OF OVERWEIGHT AND OBESITY BY BMI, WAIST CIRCUMFERENCE, AND ASSOCIATED RISK*
Disease Risk* Relative to Normal Weight
and Waist Circumference
Men 102 cm ( 40 in.) 102 cm ( 40 in.)
BMI (kg/m2) Obesity Class Women 88 cm ( 35 in.) 88 cm ( 35 in.)
Underweight 18.5 — —
Normal † 18.5–24.9 — —
Overweight 25.0–29.9 Increased High
Obesity 30.0–34.9 I High Very high
35.0–39.9 II Very high Very high
Extreme Obesity 40 III Extremely high Extremely high

*Disease risk for type 2 diabetes, hypertension, and CVD.
†
Increased waist circumference can also be a marker for increased risk even in persons of normal weight.
Original Source: WHO. (1997). Preventing and managing the global epidemic of obesity. Report of the World Health Organization Consultation of Obesity. Geneva, Switzerland: Author.
Adapted from original source for National Heart, Lung, and Blood Institute. (1998). Evidence report on detection, evaluation, and treatment of overweight and obesity. Bethesda, MD:
National Institutes of Health.

conditions: established CHD, presence of other atherosclerotic Elevated triglycerides in the patient with obesity may represent a
diseases (peripheral arterial disease, abdominal aortic aneurysm, common manifestation of a lipoprotein phenotype that includes
or symptomatic carotid disease), type 2 diabetes, sleep apnea, or elevated triglycerides, low HDL levels, and small LDL particles,
target organ damage in the hypertensive patient. People meeting a pattern considered atherogenic. 7,8, 27,28 There are several addi-
these profiles require aggressive treatment to reduce their cardio- tional factors being investigated for their contribution to the risk
vascular disease risk profiles (e.g., cholesterol-lowering therapy profile associated with obesity, for example, excess visceral adi-
and blood pressure control). 15 posity, hyperinsulinemia that accompanies insulin resistance, and
adipose tissue-released proinflammatory cytokines such as inter-
High Absolute Risk leukin-1, interleukin-6, tumor necrosis factor-
, resistin, or re-
Patients with obesity who have three or more of the following risk duced adiponectin (anti-inflammatory). 3,29,30
factors can be considered at high absolute risk for obesity-related
comorbid conditions: cigarette smoking; hypertension; low-den- Cardiovascular-Related Conditions
sity lipoprotein (LDL)-cholesterol of 160 mg/dL or more, or 130 Influenced by Obesity
to 159 mg/dL in the presence of two or more other risk factors;
high-density lipoprotein (HDL)-cholesterol less than 35 mg/dL; Several conditions related to cardiovascular disease are associated
impaired fasting glucose; family history of premature CHD; and with increased body weight (Table 38-2), for example, CHD, hy-
men aged 45 years or older or women aged 55 years or older or of pertension, and congestive heart failure, and these may require ad-
postmenopausal status. The provider should follow the estab- ditional medical management. The provider needs to address
lished guidelines in estimating absolute risk status and in treating these conditions and make the patient aware that one’s cardiovas-
the identified risk factors, 23 which are discussed in detail in other cular health is influenced by his or her weight. More importantly,
chapters. discussing the significant impact of as little as a 5% reduction in
weight may provide motivation for the patient to initiate behav-
Additional Factors That Increase ior change for weight loss.
Absolute Risk
The presence of additional risk factors (e.g., physical inactivity and Undertreated Groups
elevated triglycerides) can increase a patient’s absolute risk to a level
higher than that estimated from the preceding categories. 15,27 Two groups that providers may be reluctant to treat are patients
who are older than 65 years and smokers. However, elderly per-
sons who are obese still suffer from an increased burden of disease
DISPLAY 38-2 Waist (Abdominal) Circumference such as hypertension, diabetes, osteoarthritis (OA) and decreased
31,32
Measurement Procedure mobility. Improved pulmonary function, a reduction in anti-
hypertensive medications, and less pain from OA are benefits de-
The patient should be dressed in undergarments or in an ex- rived from intentional weight loss in the elderly people who are
amining gown. Standing to the right of the patient, palpate obese. 33 In particular, therapeutic goals for treatment of elderly
the upper hipbone to locate the right iliac crest and draw a patients with obesity should include decreasing abdominal fat and
horizontal mark just above the upper border of the iliac 34
crest. Cross that line with a vertical mark on the midaxillary preserving muscle mass and strength. Weight reduction im-
line. Place the measuring tape in a horizontal plane (paral- proves functional status and reduces concomitant risk factors in the
35
lel to the floor) around the abdomen at the level of the older population in a way similar to that in the younger adult ;
marked point and hold the tape snug to, but not compress- therefore, this subgroup should at least receive interventions to pre-
ing the skin. Take the measurement at a normal minimal vent weight gain, if not achieve weight reduction. The overweight
respiration. 15 or obese smoker carries excess risk from obesity-associated risk fac-
tors. This patient should be advised to quit, and prevention of