OBESITY - A DISEASE CAUSED BY MALADJUSTMENT - CIBOMANIA


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BODY WEIGHT - IDEAL WEIGHT - MAXIMUM PHYSIOLOGICAL WEIGHT

In healthy adults, the skeleton, viscera, skin and adnexa represent the relatively stable component of total BODY WEIGHT, while adipose tissue and muscle are the variables. Some physiological conditions (growth, pregnancy) and many others of a pathological nature (dehydrating affections, oedema, hepatosplenomegaly, tumours, myxedema, amputations, etc.), act in different ways on body weight and they must be taken into account in evaluating this and theoretical metabolism. Modest and transitory weight increases caused by water retention may also be found in menstruating women.

On the average, muscle weight corresponds to 40% of total body weight (Wohl and Goodhart - Trattato di Dietetica - Il Pensiero Scientifico: 1st Italian edition, September 1970, p. 24) but it varies greatly from one person to another on the basis of genetic factors, gender (38% in women, 42-44% in men) and in the same person depending on physical activity. The increase or decrease in the muscle component may greatly influence body weight and obviously this must not be mistaken for overweight (excess of adipose tissue) or skinniness.
If anything, it should be kept in mind that excessive development of the muscle mass, favoured by certain sports (weight-lifting, body-building) is certainly of no help to the health owing to the increased performance required of the cardiovascular and excretory systems (abnormal development of the vascular bed, increase in protein catabolites and so on); on the contrary, a sedentary life, with muscular hypotrophy and the replacement of muscle with adipose tissue, represents an important predisposing factor leading to metabolic and cardiovascular dysfunctions such as diabetes, dyslipidemia, obesity, hypertension and so on. The lack of physical activity may also lead to a slight loss of skeletal weight owing to the demineralization of bone tissue (osteoporosis).

The adipose weight of a normal male body is considered to be 12-16% of total body weight and 20-25% in the female body (Wohl and Goodhart - Trattato di dietetica - Il Pensiero Scientifico: 1st Italian edition, 1970 p. 17). However, we can still consider excellent a total body weight with adipose tissue representing up to 18% in males and 28% in females (Laurence E. et al.- Fisiologia dell'esercizio - Il Pensiero Scientifico: Italian edition, 1970, p. 367). A further increase of 10%, that is, up to 28% of the total weight of males and 38% of females, represents the MAXIMUM PHYSIOLOGICAL WEIGHT, beyond which true obesity begins.

At this point a certain dyspnoea following physical efforts that were previously well-tolerated is present in all cases and very often patients report this spontaneously: their movements are more awkward, practical problems arise (getting dressed, sweating, suffering in hot weather and so on) and, in some cases, there are also problems of a psychological nature, especially in women (irritability, self-depreciation, anxiety, depression): we are in the presence of a true illness, whether or not other concomitant pathological conditions have appeared.
The expedient and more or less conscious acceptance of a different lifestyle compatible with the new physical condition makes it possible to avoid, or at least keep to a minimum, the unfavourable psychological repercussions (obesity without complexes), but the appearance of an appetite out of all proportion to proper metabolic requirements will from that time on represent a new, serious problem to address.

And here we see the importance of a correct definition of the condition and from this to the exact finding in each case of the proper body weight and the maximum physiological weight.
We can consider IDEAL or proper a WEIGHT that allows the best functional performance of the organism and the most satisfactory state of physical and psychological wellbeing, as well as longer life expectancy all other conditions being equal. THIS WEIGHT NORMALLY CORRESPONDS TO THE PROPER PROPORTIONS OF BONE, MUSCLE AND FAT.
There are no shortcuts to determining this important parameter. It, just like the diet itself, is an individual, not a collective, fact. This parameter, from which we can immediately establish the maximum physiological weight, is essential not only in planning the weight loss, which must be agreed to by the patient, but also in calculating the metabolism (basal, total and overweight) which makes it possible to draw up a customized, complete and acceptable. Thus it is not enough to find weight and height, as required in calculating BMI, and even less the abdominal circumference, which lately appears to be replacing BMI. These parameters, in our opinion, are the sign of mental inertia which leads to uncritical acceptance of everything, and only that, which is reported in the English language.

Just as in examinations of sight, hearing and any other biophysical function or parameter that require precise and sometimes sophisticated tests, in finding a person's proper body weight, besides weight, height, gender and distribution of fat, we must also determine instrumentally the skeletal and muscle constitution, thus ensuring that a person of slender build, in a state of medium or advanced obesity, is not considered as needing a diet since the BMI is not above 24, 25 or 29, or the abdominal circumference, regardless of height, is less than (hear, hear!) 88 cm in women and 102 in men?
This point is of the greatest importance in diagnosis and treatment. We skip abdominal circumference, which deserves no comment. Even today (February 2006, see for example Emozioni e Cibo the newsletter of AIDAP, no. 17, year 2006, p. 7) we read scientific reports, probably with the contribution of public funds and thus paid for by taxpayers, in which we find that many persons believe they are overweight or thin and instead, going by the BMI they are to be considered normal and, on the contrary, many believe they are the right weight while according to BMI they are considered thin or overweight. The conclusions are that many people have the wrong idea about their bodies. We instead come to the well-grounded conclusion that the imprecise perception is not that of the persons interviewed but of the imprecise method of judgement (BMI), which takes into account only height and weight and neglects the other elements necessary in establishing the proper proportion of fat, bone and muscle, from which the proper body weight can be calculated. If we were to follow the indications given by the BMI, we would have to send away about one third of those who come to us for help; practically all those who are tall and who have a low bone and muscle weight but an excess of fat showing medium obesity are always in the normal weight category according to the BMI. Cognitive and behavioural strategies are not enough to convince these patients that their poor appearance and, in some cases, their health problems (cholesterol) are the result of an erroneous perception of their bodies. To avoid increasing the number of do-it-yourself diets, obesity and nutritional maladjustments, each patient must receive the proper response from the viewpoint of diagnosis and treatment.
Considering the importance of a person's proper or ideal weight, we believe that its evaluation is worth the time and trouble it takes to collect the necessary data through an careful objective examination, the use of scales with height rods, a tape measure showing millimetres, a fat calliper or an impedance meter; the data thus collected must be processed with the aid of a computer program. All problems must be investigated with the necessary times and means, with no banal and harmful simplifications.

As concerns the commonly used FAT CALLIPER, we believe that a pressure of 10 g/mm2 is excessive and such as to underestimate the folds in subjects with subcutaneous laxness. Indeed, the amount of fat squeezed on the sides of the pressing surface is less at the time of the first increase in weight when sometimes it is even difficult to raise the fold while it is more with the decrease in the consistency of the subcutis, which occurs after alternating phases of gaining and losing weight. In our opinion, it would be better to have an instrument that gives the value of the fold without any pressure on it by means of an electronic microcircuit with a display.

In our studio, the sum of the four folds (triceps and biceps at the third median of the left arm, left subscapular and left suprailiac regions) measured with a fat calliper supplies on the average the following measurements for persons of normal weight:

Males > 18 yrs, 36-40 mm
Females + males <19 yrs 50-54 mm

We measure five circumferences with the millimetre tape measure: the left wrist (skeletal measurement), left arm and leg (muscle, skeletal and adipose tissue measurement), the abdomen and the greater and lesser trochanters (the waist-to-hip ratio - WHR).

In our studio, all anthropometric, metabolic and dietetic measurements, case histories and clinical records, as well as printouts of diets, have been computerized for over twenty-five years and are processed by means of in-house software not to be found on the market. Considering the difficulty of such calculations, the complex composition of foods, the need to evaluate correctly a decrease in calories such as to guarantee a sufficient degree of gratification together with weight loss and, at the same time, the proper amount of nutrients, the COMPUTER is an indispensable instrument in the work of a dietician. Slipshod attitudes and improvisation cause damage to the patient since, as we have said, improper diets lead to an aggravation of the food fixation and, if repeated, may trigger serious nutritional maladjustments. No treatment is better than the wrong treatment! Greater vigilance in this field is certainly to be desired, but who are the persons competent to invigilate here? The usual experts who today on television and in conference rooms in the different regions are explaining (at the expense of the public health service and the regional administrations) that the circumference of the abdomen (without meteorism?) must not exceed 88 cm in women and 102 (neither 101 nor 103) in men?

The formulas for calculating a person's ideal weight are many, but there is still no universally accepted criterion that takes into consideration all the elements necessary to arrive at the solution. Nor can we accept the suggestion advanced by some authors (Lupi G., Battistini N.: Alim, Nutr. Met. 10: 45-52, 1989) to consider ideal the weight resulting from the average of the values given by the different formulas proposed.

At the beginning of his professional experience, the elder of the two authors of this report used the simple Broca formula (males: height in cm minus 100; females: height minus 104) adding or subtracting a kilo here and there, depending on whether or not the Grant index (height/wrist circumference) was more or less than average. It was still better than the BMI or the abdominal circumference alone! In the case of adolescents, he applied the tables in Tables Scientifiques, drawn up on the basis of measurements performed on a large number of individuals and found in Travia ("Scienza dell'Alimentazione" 1st ed.- pp. 70-75). But from the very beginning we began collecting many anthropometric measurements from our observations of patients of all ages (above the age of 6), the large majority of whom were overweight and the rest too thin. We have thus had the good fortune of determining in the field the right weight for subjects who were gaining or losing weight, and from this we collected a large number of data which later made it possible for us, with the aid of a computer, to arrive at a method for calculating a person's ideal weight, one that is quite accurate but which is constantly updated on the basis of daily clinical experience.

The elements taken into consideration are sex (S), age (A), height (H), real weight (RW), left wrist circumference (WC), left arm circumference at the 3rd median (AC), maximum left leg circumference (LC), the left arm triceps fold at the 3rd median (TF), the biceps fold (BF), the left subscapular fold (SF) and suprailiac fold immediately above the left anterosuperior iliac spines (SPF). As concerns wrist circumference (WC), which is quite important in evaluating the skeletal structure, it must be kept in mind that it varies with the variation in the fat component, increasing with increases in weight and decreasing with the loss of weight: in fact the subcutis participates in the process of gaining or losing weight, not only at the site of preference, but in all parts of the body, thus also at the wrist. From a study of 250 subjects who were losing weight or who had completed their weight loss (70 males, 180 females over 18 years of age), for each decrease of one millimetre in WC we found in males a decrease of 8.02 ± 2.48 mm in the sum of the four folds (TF+BF+SF+SPF) and in females a decrease of 10.12 ± 2.6 mm. Later, we found that the decrease in WC correlated better with the sum of the arm folds (TF+ BF) only. Supposing that in persons of normal weight this sum corresponds to 25 cm in women and 18 in males, the new thin wrist circumference (WC1), in a study performed on 2200 cases (1450 females) of persons over the age of 18, we found:
Males: WC1 = WC - (TF+BF-18)/2.02
Females: WC1 = WC - (TF+BF-25)/3.28

Based on our calculations, the net ideal weight on fasting, with reference to the bone structure (ISW) corresponds to the product √(WC1) (in cm) x H (in cm) x N, where N is a constant for sex, age category and height. Thus:
ISW = √WC1 * H * N

In calculations of the metabolism we use the ideal weight thus calculated, but we are careful to inform the patient that since it cannot be calculated to less that one kilogram, in most cases the weight is to be considered ideal up to + 6% of the figure found. In women with a very light bone structure, however, to avoid the appearance of unsightly conditions at the trochanters, the range cannot be above + 2-3% of ISW.
By performing the calculation with a computer, the result is obviously immediate. Below is the table of the constants by sex, age category and height.

AGE MALES FAMELES
E H N H N
>25 >179
170-179
160-169
<160
10
9.9
9.75
9.5
>169
160-169
150-159
140-149
<140
8.9
8.72 + .02*(H-165)
8.4 + .02*(H-155)
8.28 + .02*(H-145)
7.95
19-25 >179
170-179
160-169
<160
9.9
9.8
9.74
9.7
>169
160-169
150-159
140-149
<140
8.7
8.61 + .02*(H-165)
8.3 + .02*(H-155)
8.14 + .02*(H-145)
7.9
16-18 >169
160-169
<160
9.67
9.2
9
>169
160-169
150-159
140-149
<140
8.64
8.36 + .02*(H-165)
7.96 + .02*(H-155)
7.85 + .02*(H-145)
7.8
13-15 >169
160-169
150-159
<150
9.4
8.85 + .02*(H-165)
8.2 + .02*(H-155)
7.5 + .02*(H-145)
>159
150-159
<150
8.52
7.78 + .02*(H-155)
7.5 + .02*(H-145)
<13 >159
150-159
140-149
130-139
9.1
8.24 + .02*(H-155)
7.34 + .02*(H-145)
6.26 + .02*(H-135)
>159
150-159
140-149
130-139
8.04
7.83 + .02*(H-155)
7.06 + .02*(H-145)
6.78 + .02*(H-135)
MALES AND FEMALES <13 aa H <130 N = 5.68

Table1 - A = age -     H = height in cm -     N = constant number.    ( 1 inch=2,54 cm -- 1 lb = 0,4536 kg. )

The PIS obtained from these calculations is proved highly reliable in 95% of patients. In the remaining 5% of people, whose body shape is often visibly different from the standard reference, we calculate the PIS, with sufficient approximation, using the sum of the folds underskin, keeping in mind that 4.5 mm of exceeding folds correspond to 1 kg of exceeding fat. It can be also useful to compare the exceeding fat resulting from the tables of Womersley and Durin, however, in the body standard composition, it regards the average weight of 12% fat in men and 22% in women, against the 15% and 25% of our calculations.

As is known, the normal skeletal structure is accompanied by a corresponding development of muscle mass and therefore, when this is the case, the ideal skeletal weight (ISW) can be superimposed on the ideal skeletal-muscle weight (ISMW); in other cases the ISMW will be greater or lesser compared to the ISW, depending on whether or not the muscles are developed more or less than average.
Thus evaluation of the ISMW is essential in attributing the deviation from normal weight to fat or muscle. In our calculations, we assume mean muscle weight at 43% of normal body weight in males and 38% in females. With reference to this mean, and by finding an average muscle index differentiated by gender and degree of overweight, we assess the individual's muscle component obtained by measuring the circumference of the arm (3rd median) and the leg (maximum circumference at the calf) corrected by the bone and fat components..

Whoever has any experience at all in dietetics knows the importance of these parameters. As an example, here is the case of one of our 17-year-old female patients: height 168 cm, net weight 58.4 kg and therefore a BMI of 20.69 (!). When dressed, she appeared to be in perfect physical shape, but the objective examination revealed a considerable increase in the fatty component, with 70 mm as the sum of the four folds (compared to the theoretical 52) and a clear prevalence of the hypogastrium and the two trochanters, which made an unpleasant contrast with the other parts of the body. Her ideal weight (ISW) was 52.1 kg, ISMW was 51.9 kg, maximum physiological weight 62.5 kg, the abdominal circumference 74 cm, the relative body weight (RBW) 112. As can be seen, the only parameters of no use in understanding the case were the BMI and abdominal circumference, which on the contrary give the wrong impression concerning the reality of the case.
In the case described, if we do not take into account what we have said up to now, it may appear to be exclusively a question of aesthetics since the patient, apart from the slight unsightliness of her appearance, presented no physical element pointing to a pathology of any kind. Unfortunately, that was not the case. Suffice it to say that at that point there was, and still is, a nutritional maladjustment; to counter the progressive increase in weight the patient is forced to follow a aware, risky piloting of her food intake (food fixation) which does not always have a happy ending. In most cases, when inhibitory mechanisms fail, obesity sets in (in our case four kilos from the maximum physiological weight); unfortunately, in other cases the repeated attempts to follow dietary restrictions that are doomed to failure, the inevitable repercussions on the health deriving from the continuation of the nutritional maladjustment as well as specific psychological conditions and some environmental circumstances, may lead to the onset of a serious disturbance in eating behaviour. We are thus dealing with a true health problem and this is the best time to intervene in a suitable way with information, psychological support and diet (secondary prevention) so as not to have to intervene in the future on cases of advanced obesity or, what is even worse, on cases of pathological disturbances in eating behaviour.
An unsightly appearance itself is a true illness when it leads to psychological distress: only physicians who do not know how to deal with such cases can settle for trying to persuade patients to accept their physical imperfections.

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