One of the most important steps a woman can take to maintain her health and prevent chronic disease is to maintain a healthy weight. Obesity has been linked with increased incidence of dyslipidemia, hypertension, Type II diabetes, coronary artery dis- ease, stroke, gallbladder disease, gout, osteoarthri- tis, sleep apnea, and colon cancer [35]. Women who are obese are also at increased risk of poor preg- nancy outcomes, miscarriage, polycystic ovarian syndrome, and breast and endometrial cancers [22, 36].
Recent results from the Centers for Disease Control and Prevention’s National Health and Nutrition Examination Survey (NHANES III) indi- cate that overweight and obesity are on the rise among all age groups in the United States. The same data reveal that 35 percent of American adults of ages 20 to 74 years are overweight and that an ad- ditional 27 percent of adults are obese [37].
Women, and in particular minority women, are dis- proportionately affected by this epidemic and have the highest prevalence of both overweight and obe- sity across nearly all age groups and income levels.
Data show that 33 percent of non-Hispanic whites, 52 percent of non-Hispanic blacks, and 50 percent of Hispanic women are overweight [38].
Although overweight and obesity are often used as interchangeable terms, they do in fact refer to different conditions. The National Center for Chronic Disease Prevention and Health Promotion defines overweight as an excess in body weight in relation to height. Obesity, on the other hand, is de- fined as an excessively high amount of body fat in relation to lean body mass. Being overweight does not always mean having an excess in body fat.
Professional athletes, for example, may have little body fat but may weigh more than others of their same height due to larger muscle mass. In the gen- eral population, however, being overweight and having an excess of body fat are usually coexisting conditions.
There are several methods commonly used to determine desirable weights for individuals and to define clinical obesity. One such method, exempli- fied by the Metropolitan Life Insurance tables, is based on population averages. These tables provide desirable weight ranges for women and men of dif- ferent height and body frame sizes. The recom- mended weight ranges are based on weights that have been associated with greater longevity. This
method to determine desirable weight is fraught with problems, including the fact that the data were derived from purchasers of life insurance—not from a random cross-section of the U.S. population—and include the weight of clothes and shoes. Another significant problem with this method is that it does not account for degree of body fat, which is a fac- tor that more accurately predicts propensity for weight-related disease.
The Body Mass Index (BMI), on the other hand, is highly predictive of degree of body fat and is the federally recommended measurement to clas- sify overweight and obesity [39]. Table 6-14 illus- trates how to find a person’s BMI. BMI is calculated by dividing a person’s body weight in kilograms by the square of his or her height in meters (kg/m2) or by multiplying an individual’s weight in pounds by 703 and then dividing by the height in inches squared (lbs ¥703/in2). Table 6-15 shows BMI cal- culations in pounds and inches. Although exact cutoff values to define overweight and obesity are still being debated, research has clearly demon- strated that in adults, a BMI greater than 25 to 27 is associated with increased morbidity and mortal- ity. At a BMI of 27, for example, the risk for dia- betes and hypertension is three times greater than normal and the risk for high serum cholesterol level is two times greater than normal [5]. The most re- cent U.S. federal guidelines define overweight as a BMI of 25 to 29.9 and obesity as a BMI of 30 and above [35]. Table 6-16 provides classifications for BMI that can be used to assist in conjunction with BMI calculation to determine whether or not an in- dividual is at an appropriate weight for his or her height.
A drawback of the BMI measurement is that it yields no information on the distribution of fat in the body, which is also an important determinant of health risk. Upper-body obesity, in which there is an excess of abdominal fat, is associated with increased risk of heart disease, hypertension, and diabetes [35]. This type of obesity is referred to as android obesity. Because progesterone encourages fat to ac- cumulate preferentially in the lower body, women are less likely than men to develop upper-body obe- sity. This does not mean, however, that women are immune to upper-body obesity. There are two ways to assess excess abdominal fat. One is to perform a measurement of waist circumference. To do this, the clinician should use a tape measure to measure the distance around the smallest area below the rib cage and above the umbilicus. For women, a waist meas- urement greater than 35 inches (88 centimeters) is
considered a predictor of risk factors and ailments associated with obesity [35]. Waist-to-hip ratio (WHR) is another way of assessing fat distribution.
It is determined by dividing waist circumference by hip circumference. Hip circumference is obtained by measuring the distance around the largest extension of the buttocks. A WHR of 1.0 or greater is consid- ered to be associated with an increased risk of ad- verse health consequences [40]. It should be noted that overall obesity is more closely related to in- creased risk of morbidity and mortality than either increased waist circumference or increased waist-to- hip ratio. These measurements should therefore be used in conjunction with BMI to evaluate an indi- vidual’s risk for overweight and obesity related dis- eases. Furthermore, in individuals with a BMI ≥35 kg/m2, waist circumference and waist-to-hip ratio add little to no predictive power for disease risk.
The National Institutes of Health recommends a ten-step approach for primary care providers in treating overweight and obesity:
1.Measure height and weight.
2.Measure waist circumference.
3.Assess comorbidities.
4.Determine whether a patient needs treatment.
5.Assess whether a patient is ready and motivated to lose weight.
6.Determine which diet should be recommended.
7.Determine and discuss a physical activity goal.
8.Review a weekly food and activity diary.
9.Provide the patient with literature on physical activity, behavioral change, and diet modifica- tion. Provide guidelines for food and activity diary.
10.Record the goals that have been set with the pa- tient and follow up to assess progress on a reg- ular basis.
These steps include body weight, height, and BMI assessments as well as an assessment of risk status and of daily food intake and physical activ- ity. Behavioral, exercise, diet, pharmacological, and surgical interventions are then outlined based on an individual’s risk profile and degree of overweight and/or obesity.
Much focus has been placed in the media and among the general population on the concept of calorie counting. Calories, kcalories, or kilocalories are a measure of the energy content in foods. One kilocalorie is the heat needed to raise the tempera- ture of one kilogram of water by one degree Celsius.
In general, caloric intake should be the same as
Normal Overweight Obese Extreme Obesity
BMI 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54
Height
(inches) Body Weight (pounds)
58 91 96 100 105 110 115 119 124 129 134 138 143 148 153 158 162 167 172 177 181 186 191 196 201 205 210 215 220 224 229 234 239 244 248 253 258 59 94 99 104 109 114 119 124 128 133 138 143 148 153 158 163 168 173 178 183 188 193 198 203 208 212 217 222 227 232 237 242 247 252 257 262 267 60 97 102 107 112 118 123 128 133 138 143 148 153 158 163 168 174 179 184 189 194 199 204 209 215 220 225 230 235 240 245 250 255 261 266 271 276 61 100 106 111 116 122 127 132 137 143 148 153 158 164 169 174 180 185 190 195 201 206 211 217 222 227 232 238 243 248 254 259 264 269 275 280 285 62 104 109 115 120 126 131 136 142 147 153 158 164 169 175 180 186 191 196 202 207 213 218 224 229 235 240 246 251 256 262 267 273 278 284 289 295 63 107 113 118 124 130 135 141 146 152 158 163 169 175 180 186 191 197 203 208 214 220 225 231 237 242 248 254 259 265 270 278 282 287 293 299 304 64 110 116 122 128 134 140 145 151 157 163 169 174 180 186 192 197 204 209 215 221 227 232 238 244 250 256 262 267 273 279 285 291 296 302 308 314 65 114 120 126 132 138 144 150 156 162 168 174 180 186 192 198 204 210 216 222 228 234 240 246 252 258 264 270 276 282 288 294 300 306 312 318 324 66 118 124 130 136 142 148 155 161 167 173 179 186 192 198 204 210 216 223 229 235 241 247 253 260 266 272 278 284 291 297 303 309 315 322 328 334 67 121 127 134 140 146 153 159 166 172 178 185 191 198 204 211 217 223 230 236 242 249 255 261 268 274 280 287 293 299 306 312 319 325 331 338 344 68 125 131 138 144 151 158 164 171 177 184 190 197 203 210 216 223 230 236 243 249 256 262 269 276 282 289 295 302 308 315 322 328 335 341 348 354 69 128 135 142 149 155 162 169 176 182 189 196 203 209 216 223 230 236 243 250 257 263 270 277 284 291 297 304 311 318 324 331 338 345 351 358 365 70 132 139 146 153 160 167 174 181 188 195 202 209 216 222 229 236 243 250 257 264 271 278 285 292 299 306 313 320 327 334 341 348 355 362 369 376 71 136 143 150 157 165 172 179 186 193 200 208 215 222 229 236 243 250 257 265 272 279 286 293 301 308 315 322 329 338 343 351 358 365 372 379 386 72 140 147 154 162 169 177 184 191 199 206 213 221 228 235 242 250 258 265 272 279 287 294 302 309 316 324 331 338 346 353 361 368 375 383 390 397 73 144 151 159 166 174 182 189 197 204 212 219 227 235 242 250 257 265 272 280 288 295 302 310 318 325 333 340 348 355 363 371 378 386 393 401 408 74 148 155 163 171 179 186 194 202 210 218 225 233 241 249 256 264 272 280 287 295 303 311 319 326 334 342 350 358 365 373 381 389 396 404 412 420 75 152 160 168 176 184 192 200 208 216 224 232 240 248 256 264 272 279 287 295 303 311 319 327 335 343 351 359 367 375 383 391 399 407 415 423 431 76 156 164 172 180 189 197 205 213 221 230 238 246 254 263 271 279 287 295 304 312 320 328 336 344 353 361 369 377 385 394 402 410 418 426 435 443
Source:Adapted from Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report.
that height and weight. Pounds have been rounded off.
114
Factors Affecting Necessary Caloric Intake
TABLE 6-18
• Body size
• Age
• Height
• Weight
• Activity level/Base Metabolic Rate (BMR)
• Pregnancy status
• Lactation status
caloric output. Table 6-17 contains the general guidelines for caloric intake for moderately active women. It should be kept in mind that these recom- mendations are based on averages and are not the best indicator of individual caloric needs. Body frame size and amount of average physical daily ac- tivity are two of the many factors that can affect caloric needs (see Table 6-18). Dietary therapy, the cornerstone of treatment of overweight and obesity,
aims at a moderate reduction in caloric intake to achieve a slow, progressive, weight loss of one to two pounds per week as well as modification in the composition of the client’s diet to minimize risk fac- tors for disease. A reduction in caloric intake of 500 to 1000 calories per day from a woman’s current level is usually sufficient to achieve the desired weight loss. Moderate caloric reduction is usually all that is necessary although in some cases more marked reduction may be necessary. During the pe- riod of active weight loss, it may be necessary to drop daily caloric intake to a level that is lower than what will be needed to maintain desired weight level. For women, this usually means a diet contain- ing 1000 to 1200 kcal/day. The level of caloric in- take should not be too low (less than 800 kcal/day is too low), and the overall goal should be to aim for the target caloric intake that will be required to maintain weight at a desired level. Individuals plan- ning to start calorie-cutting diets should first consult with a dietician to assess caloric needs and to deter- mine what level of calorie restriction is safe.
Practitioners should keep in mind that women who are pregnant, lactating, or acutely ill should not be placed on diets that restrict calories.
In addition to diet therapy, a woman will need a physical activity regimen, behavioral therapy, and sometimes pharmacotherapy or surgery to achieve the necessary weight loss. The midwife who deter- mines that a woman needs to be placed on a low calorie diet or on medications for weight loss should consult with or refer the woman to a dieti- cian or physician. Consultation or referral is always indicated in the case of women who are extremely obese, those who need a very low calorie diet, or those who have untreated or uncontrolled comor- bidities such as hypertension or diabetes.