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Vol. 60. Issue 9.
Pages 992-993 (September 2007)
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Limitations in the Clinical Assessment of Obesity: Comments on the American Heart Association's 2006 Statement
Limitaciones de la valoración clínica de obesidad: reflexiones a propósito de la Declaración de la American Heart Association de 2006
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Alberto Moralesa, Jaume Marrugatb, Antonio Cocac
a Cardiocentro Ernesto Che Guevara, Santa Clara, Cuba
b Instituto Municipal de Investigación Médica, Barcelona, Spain
c Unidad de Hipertensión, Instituto de Medicina y Dermatología, Hospital Clínico, Universidad de Barcelona, Barcelona, Spain
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To the Editor:

The American Heart Association (AHA) update on obesity has recently been published.1 The purpose of this letter is to comment briefly on the limitations of the clinical assessment of obesity.

The link between obesity and cardiovascular risk (CVR) has traditionally been controversial. Although the Framingham study already observed in 1967 that higher body weight raised an individual's probability of cardiovascular disease (CVD),2 it was only in 1998 that the AHA (American Heart Association class) first recognized obesity as a major independent cardiovascular risk factor.3 The explanation to this problem lies precisely in the limitations of obesity assessment, which should be expressed as a percentage of body fat,4,5 but is difficult to quantify clinically.5 Numerous anthropometric variables have been used for this purpose, but body mass index (BMI) is the most highly extended to assess body weight and, along with abdominal circumference, is the method recommended by the AHA.1

The key limitations in the clinical assessment of obesity include the following:

1. Available indexes do not identify the percentage of body fat (ie, they do not discriminate between muscle, fat, and bone).

2. The fat-to-muscle ratio varies with age, gender, ethnic group, and race.1,6,7

3. The BMI varies with body proportions and may tend to underestimate the prevalence of obesity in taller subjects and to overestimate it in shorter subjects, although this should be confirmed in larger populations.8 Moreover, there are multiple confounding factors that can mask the actual relationship between obesity and CVR.

4. Smoking (associated with a lower body weight).6

5. Comorbidity of the obese patient.1

6. Underweight subjects (BMI <18.5) have an elevated prevalence of smoking, chronic diseases, and risk of death from cancer.9

7. CVR varies with height10 and is lower in tall subjects.11

8. Other: physical exercise,12 diet,13 etc.

In summary, the main clinical indexes for defining obesity (BMI, abdominal circumference, and even waist/hip circumference14) have limitations, although there are practical alternatives such as a combined assessment of weight1 and degree of physical activity.12,15 This would make it possible to identify sedentary obese individuals, a subgroup with greater CVR12 and, theoretically, a higher percentage of body fat.

Bibliography
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Poirier P, Giles TD, Bray GA, Hong Y, Stern JS, Pi-Sunyer FX, et al..
Obesity and cardiovascular disease: pathophysiology, evaluation, and effect of weight loss: An update of the 1997 American Heart Association Scientific Statement on Obesity and Heart Disease From the Obesity Committee of the Council on Nutrition, Physical Activity, and Metabolism..
Circulation, 113 (2006), pp. 898-918
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Kannel WB, LeBauer EJ, Dawber TR, McNamara PM..
Relation of body weight to development of coronary heart disease: The Framingham Study..
Circulation, 35 (1967), pp. 734-44
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American Heart Association call to action: obesity as a major risk factor for coronary heart disease..
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Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: the evidence report. Bethesda, MD: US Department of Health and Human Services, National Institutes of Health; 1998. Available from: http://www.nhlbi.nih.gov/guidelines/ obesity/ ob_gdlns.htm
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Grundy SM..
Obesity, metabolic syndrome, and cardiovascular disease..
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Seidell JC, Flegal KM..
Assessing obesity: classification and Epidemiology..
Br Med Bull, 53 (1997), pp. 238-52
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Prentice AM, Jebb SA..
Beyond body mass index..
Obes Rev, 2 (2000), pp. 141-7
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An alternative to body mass index for standardizing body weight for stature..
Q J Med, 93 (2000), pp. 589-96
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Wilson PW, d'Agostino RB, Sullivan L, Parice H, Kannel WB..
Overweight and Obesity as Determinants of Cardiovascular Risk. The Framingham Experience..
Arch Intern Med, 162 (2002), pp. 1867-72
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Silventoinen K, Zdravkovic S, Skytthe A, McCarron P, Herskind AM, Koskenvuo M, et al..
Association between Height and Coronary Heart Disease Mortality: A Prospective Study of 35,000 Twin Pairs..
Am J Epidemiol, 163 (2006), pp. 615-21
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Palmer JR, Rosenberg L, Shapiro S..
Stature and the risk of myocardial infarction in women..
Am J Epidemiol, 132 (1990), pp. 27-32
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Li TY, Rana JS, Manson JE, Manson JE, Willet WC, Stampfer MJ, et al..
Obesity as compared with physical activity in predicting risk of coronary heart disease in women..
Circulation, 113 (2006), pp. 499-506
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Covas MI, Nyyssonen K, Poulsen H, Kaikkonen J, Zunft HJ, Kiesewetter H, et al..
The Effect of Polyphenols in Olive Oil on Heart Disease Risk Factors A Randomized Trial..
Ann Intern Med, 145 (2006), pp. 333-41
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Yusuf S, Hawken S, Ounpuu S, Bautista L, Franzosi MG, Commerford P, et al..
Obesity and the risk of myocardial infarction in 27,000 participants from 52 countries: a case-control study..
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Elosúa R, García M, Aguilar A, Molina L, Covas MA, Marrugat J, et al..
Validation of the Minnesota Leisure Time Physical Activity Questionnaire in Spanish Women..
Med Sci Sports Exerc, 32 (2000), pp. 1431-7
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Revista Española de Cardiología (English Edition)

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