We may caution overweight patients against the perils of carrying extra body weight, regardless of the excuse.
We may caution overweight patients against the perils of carrying extra body weight, regardless of the excuse. But, which of these heavier patients is actually at risk and what, precisely, are they at risk for? Becoming familiar with just a few, simple basics in anthropometric measurements can assist you in identifying which of your patients are at risk for cardio-metabolic syndrome. This article will discuss some of these measurements and what they may indicate regarding your patients’ risk levels. This information adds to the DCs’ already extensive physical exam, but might be well worth considering. From a service/primary care point of view, it is important and easy and adds value to the initial exam.
|Familiarity with just a few basics in anthropometric measurements can assist you in identifying which of your patients are at risk for cardio-metabolic syndrome.
Obesity and Metabolic Syndrome
Obesity, and, in general, the diagnosis of metabolic syndrome, has become epidemic and is quickly rising in the younger population, setting the stage for a life of morbidity and disease. Canadian statistics in 2004 showed 59 per cent of the population were overweight and 26 per cent of children/adolescents were overweight. Metabolic syndrome is a disease of lifestyle – poor food choices, stress, lack of exercise, toxicities. Assessing the risk factors for this, in your initial exam, is something that, as a primary care provider, you can do in a just a few minutes and then encourage intervention as soon as possible.
The weight scales alone are not enough to assess risk. More and more, we see the “skinny” fat patient develop cardiovascular disease or diabetes despite not fitting the previously accepted profile of the overweight person who was a risk for these conditions. Alternatively, the person who weighs in heavy and would appear to be at high risk for morbidity, may not suffer at all. It comes down to understanding body composition.
Early intervention is so important in mitigating this disease, it would seem prudent as primary health-care providers to know what to look for and how to show your patients their risk just by looking at their body composition. It starts with remembering that scales are helpful with initial assessment, but they only assess weight, not fat. To assess fat, there are several factors to consider – someone may be overweight but not over-fat. Conversely, someone may be of normal weight but over-fat. Assessing leanness versus lightness is the goal.
1) Body Mass Index (BMI)
BMI was created back in the 1800s and is defined as the individual’s body mass in kilograms divided by his or her height in metres squared. A simple chart can be used to assess a patient’s BMI and, although it is a useful indicator, it does not account for a high BMI due to muscle mass versus fat mass. Someone who weight trains and has little body fat may appear to be heavy by his or her BMI while a “skinny” fat person may appear to be at low risk with a low BMI despite having a high fat content.
Note that BMI is not to be used as listed for children.
2) Waist to Hip Ratio (WHR)
WHR, versus BMI, is now considered a better predictor of all causes of mortality in older adults. This is a good way to assess if someone who is considered over-fat is actually over-VAT (visceral adipose tissue) or if they are over-SAT (subcutaneous adipose tissue). This is the apple versus the pear comparison; that is, the over-VAT person is the apple body, also known as android obesity, and the over-SAT person is the pear body, otherwise known as gynoid obesity. According to reports from the National Institutes of Health (NIH), visceral fat (fat within the peritoneal cavity) is linked to insulin resistance, glucose intolerance, dyslipidemia, hypertension and coronary artery disease (NIH).
Increased visceral adiposity is inversely related to adiponectin levels, an important protein that modulates glucose and fatty acid catabolism. Low levels of adiponectin leads to insulin resistance, which leads to hyperlipidemia, diabetes and hypertension – all resulting in atherosclerosis and CVD. Inflammation is another factor to be considered as visceral adipocytes are strong producers of inflammatory cytokines and inflammation is a powerful stimulator of many diseases, including metabolic syndrome and CVD.
3) Waist Circumference (WC)
Waist circumference will certainly reveal any excess fat carried above the belt line (as long as you don’t cheat and wear the belt too low!) Waist circumference is used as one of the criteria for establishing the diagnosis of metabolic syndrome.
Metabolic syndrome is diagnosed if three of the five criteria are present:
- Increased WC
- Blood pressure >130/85
- Fasting blood glucose: = or >6.1 mmol/L
- Triglyceride: = or >1.7 mmol/L
- HDL (men: = or <1.0 mmol/L; women: = or <1.3 mmol/L)
4) Bioimpedance Analysis – A Step Further
Bioimpedance analysis (BIA) determines the impedance of electrical current through body tissues. It is then used to estimate total body water. This is used to estimate fat-free body mass versus body weight, and hence total body fat. It is another step in assessing body composition, if one wants to add an extra effort to assessing risk; however, it is not necessary for simply assessing baseline risk for metabolic syndrome.
Taking the time to obtain a few measurements will perhaps reveal, to your patients, their risk for cardio-metabolic issues, and ensuing disease, based on their body composition. Coupling this with asking them to have a blood workup to obtain their lipid levels, fasting glucose (better yet, fasting insulin, as insulin will be elevated before blood glucose will show elevation), you may quickly identify those patients who are inching toward metabolic syndrome so that you can advise and/or help them intervene early before they enter a state of disease progression.
Sources Used for this Article
- Lau D et al. 2006 Canadian clinical practice guidelines on the management and prevention of obesity in adults and children. CMAJ April 10, 2007, 176(8).
- Matsuzawa Y et al. Artherscler Thromb Vasc Bio 2004:24, 29-33.
- Murray S. Is waist to hip ratio a better marker of cardiovascular risk than body mass index? CMAJ January, 2006, 174(3).
- Waist circumference and waist–hip ratio: report of a WHO expert consultation, Geneva, 8–11.
Dr. Victoria Coleman is a 1994 graduate of CMCC and a BSc in Kinesiology specializing in Fitness Assessment and Exercise Counseling. In working with patients over the years, she made it her mission to teach people that everything you eat, breathe, drink, and think affects your health. This fuelled her desire to further expand her career and continue her studies. She is an avid follower of the Institute for Functional Medicine and is currently working toward her certification in Functional Medicine. Dr. Coleman is also the president of Douglas Laboratories/Pure Encapsulations Canada.
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