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4 Obesity Epidemic in the United States a Cause of Morbidity and Premature Death

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4 Obesity Epidemic in the United States a Cause of Morbidity and Premature Death Morbid Obesity 61 4 Obesity Epidemic in the United States A Cause of Morbidity and Premature Death Donna M. Hunsaker, MD and John C. Hunsaker III, MD, JD CONTENTS BACKGROUND PREMATURE DEATH RELATING TO OBESITY PEDIATRIC OVERWEIGHT AND OBESITY REFERENCES SUMMARY Regarded as preeminent health issues in the Western world, overweight (OW) and obesity (OB) are overwhelmingly prevalent in the United States. Currently the United States, characterized by one writer as “Fat Land,” leads the epidemic of fat-related morbidity. Approximately 190 million Americans (approx 64% of the population) are estimated to be OW or OB. The energy balance equation defining relative homeostatic roles of energy intake and expenditure is not the sole etiological factor in a genetically defined subset of individuals with OB and OW. Beyond this subset, the energy balance is cru- cial for maintaining a healthy weight, free of significant premature natural From: Forensic Pathology Reviews, Vol. 2 Edited by: M. Tsokos © Humana Press Inc., Totowa, NJ 61 62 Hunsaker and Hunsaker disease. In the Western civilization, there is a ready supply of a high-energy, low-nutrient foods, which, when coupled with decreased physical activity, promote adiposity. OB-related complications and risks of premature death are growing concerns to the medical community as the costs of treatment for this essentially preventable condition explode continually in the wake of rising trends of OW and OB. In the adult age ranges of greater than 20 years, OW and OB have increased to 54.9% within the last decade. Life expectancy declines by 20 years if a person is OB by the age 20. A high prevalence (15%) of American children between 6 and 19 years is classified as OW or OB. OB elderly report a poorer health-related quality of life in comparison to nonobese age-matched individuals. In the United States alone, approx 300,000 adult deaths are attributed annually to OB complications. Extensive research addresses the effects of OW/OB on the health of Americans. Many health care professionals now classify OW/OB in the general public as a chronic disease state, resulting in a vast array of medical comorbidities with debilitating psy- chological and behavioral sequelae. In forensic death investigation, autopsy findings correlate well with this clinical diagnosis. Calculating the body mass index (BMI) and measurement of abdominal circumference (AC) offers the most accurate postmortem diagnosis of OW and OB. In addition to BMI and AC, less specific parameters (i.e., adipocyte hypertrophy and hyperplasia) are included in the definition of OB. Clearly, evaluation of adipocyte size and quantity is impractical either antemortem or postmortem. In our experience, many OW or OB individuals coming to autopsy even without antemortem clinical diagnoses have died predominately of complications of ischemic heart disease, inclusive of hypertensive cardiovascular disease and atherosclerotic coronary artery disease. Other significant extra-cardiac causes of death directly related to OW and OB are ascribed to complications of diabetes mellitus, lower extremity deep venous thrombosis and pulmonary thromboemboli, liver dis- ease, and acute and chronic respiratory embarrassment. Both nonfatal and lethal complications of surgery—either unrelated to or specifically for treatment of OB—also occur at higher rates in the OB patient. Key Words: Obesity; overweight; body mass index (BMI); ischemic heart disease; medical complications of obesity; chronic disease; premature death; forensic autopsy; obesity epidemic. 1. BACKGROUND 1.1. Aspects of the Obesity Epidemic Hippocrates observed that “Sudden death is more common in those who are naturally fat than lean” (1). Overweight (OW) and obesity (OB) are the Morbid Obesity 63 most common nutritional disorders in America (2). Greater morbidity and poor quality of health are more prevalent in OB than in tobacco abuse, alcoholism, and poverty (3). OB, although viewed by the public as a cosmetic problem, is a major health problem. If current trends continue in the United States, OB will soon overtake smoking as the primary preventable cause of death (4). The National Health and Nutrition Examination Survey (NHANES) and other researchers record a drastic increase in adult OB from 14.5% between 1976 and 1980 to 22.5% between 1998 and 1999 (5). Approximately 63% of men and 55% of women older than 25 years are considered OW or OB in the United States. One-fifth of American adults have a body mass index (BMI) greater than 30 (for definition and measurement see Section 1.2). Both genders with a BMI greater than 30 have a 50 to 100% higher mortality rate than those with a BMI less than 25. A BMI between 25 and 30 portends an increased mortality rate between 10 and 25% (6). A BMI greater than 40 strongly relates to an increased risk of various diseases and premature death. Seventy-five percent of class III (extreme) OB adults have at least one comorbid condition. In the 18- to 29-year-old population, a significant trend in class III OB has also been established in comparison to 1975 studies (7). A current comprehensive review with recommendations for the diagnosis and treatment of OW and OB was published by Robert H. Eckel in 2003 (8). 1.2. Definitions and Measurements of Obesity The traditional definition of morbid or severe OB is weight at least 45 kg above normal weight or 100% greater than ideal body weight defined by stan- dard life insurance tables. The Metropolitan Life Insurance Company weight- for-height tables have traditionally defined normal weight range. These tabulations are seriously limited by invalidated frame-size estimation, reli- ance on Caucasian populations, and table derivation from mortality data. Insurance weight tables have predicted mortality outcomes but not morbidity. BMI is also referred to as the Quetelet index, which combines the measure- ment of height and weight and assumes that any variation of weight in persons of the same height is predominantly due fat mass (6,9). BMI, the most com- mon means of assessment, provides better accuracy in measurement of total body fat than weight alone. The BMI calculation is kilograms of body weight per meter-squared height (kg/m2). Simply stated, a calculated BMI of 30 sug- gests an overall excess weight gain of 30 pounds. BMI does not directly measure body fat level and also does not measure body fat distribution. The 1995 fourth edition of the dietary guidelines for Americans recommends that adults maintain a healthy weight corresponding to a BMI between 19 and 25 (10). The BMI provides an excellent measure of 64 Hunsaker and Hunsaker weight adjusted for height in individuals, but is not a perfect measurement of adiposity because it does not distinguish lean from fat mass. Therefore, BMI requires conservative interpretation: very muscular individuals have a higher calculated BMI without an increased risk of premature morbidity or mortality. Similarly, the elderly, with less muscle density, have a lower calculated BMI, even with greater adiposity (6,9). Table 1 shows BMI and other types of body fat measurement with their limitations (5,6,9–14). Individuals with increased abdominal fat relative to weight are more greatly predisposed to clinically significant cardiovascular disease. BMI com- bined with measurement of waist circumference (WC) predicts relative dis- ease risks (DR) coexistent with OW and OB (13,15,16). Table 2 shows the weight categories with associated DR. WC assesses abdominal fat, and identi- fies those individuals in the “normal or overweight” BMI classes who have a resultant relative increased risk of disease. Its simplicity of measurement is clinically useful. WC is not helpful in individuals with a BMI greater than 35. Men and women with larger WC (>102 and 88 cm [40 and 35 inches], respec- tively) have increased DR for diabetes mellitus (DM), hypertensive and ath- erosclerotic cardiovascular diseases, and dyslipidemia. Clinicians assign these individuals one risk category higher than defined by the calculated BMI (Table 2). WC smaller than the standard cutoff points, even at a given abdominal adiposity, predicts an increased incidence of risk for several chronic diseases: in men WC of 94 to 102 cm (37–40 inches) carries a relative risk of 2.2 for one or more cardiovascular risk factors; in women, a relative risk of 1.5 for car- diovascular disease at WC of 80–88 cm (32–35 inches). Insulin-resistant DM, hypertension, hyperlipidemia, and hyperandrogenism in women are linked to an increase in intra-abdominal and upper body fat. Use of the WC modality requires that other causes of increased abdominal girth, for example, ascites or elderly kyphosis, be ruled out (5,13,14). The waist-to-hip ratio (WHR), a measure of the intra-abdominal and abdominal subcutaneous fat, more directly impacts DR than buttock and lower extremity subcutaneous fat. The WHR greater than 0.9 in women and greater than 1.0 in men is abnormal (13,14). The term “overweight” refers to a BMI between 25 and 30. Clinically, the classification represents a medically significant category because it pre- dicts potential risk factors such as hypertension and glucose intolerance. Increased body weight of 20% above desirable is associated with comorbidities that both decrease overall health and increase morbidity (5). The classifica- tion of OW individuals has remained relatively stable during the past three decades. The prevalence of OB has increased more than 50% within the past 10 to 15 years from 14.5 to 22.5% (10). The 1995 dietary guideline advisory Table 1 Morbid Obesity 65 Measurements of Body Adiposity Methods of measurement Measurement Interpretation Limitations Body mass index (BMI) Weight (kg)/height (m2) or BMI >25 B disease Inconsistencies with muscular lbs × 703/in2 risk (DR) build and elderly atrophy Waist circumference (WC) Horizontal abdominal measure- WC >40/35 in ment at iliac crest level (102/88 cm) / : B DR Unhelpful measurement in BMI >35.
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