Obesity

Definition & Diagnosis of Overweight &

Obesity
Obesity is a disorder of body composition defined by
a relative or absolute excess of body fat and
characterized by several remarkable features.
Obesity is best defined as the presence of an
abnormal absolute amount or relative proportion of
body fat.
The presence of excess body fat usuallybut not
alwaysresults in higher body weight.
Obesity is most commonly assessed in clinical
practice by measurement of the body mass index
(BMI) the recommended basis for classifying
overweight and obesity
The term "morbid obesity" has also been used to
emphasize the extreme health risks of body weights
above 150 kg.
 Stability Factors: Energy Expenditure
Changes in Response to Changes in
Body Weight
The energy balance equation is dynamic, not static, and this may explain why there is long-term relative stability
of body weight and fat stores. One of the key points about energy balance and weight that is not generally
appreciated is that most people do not continuously and relentlessly gain or lose weight. Over the long term, there
tends to be relative stability of body weight and body fat stores in most individuals, at least in comparison with the
energy throughput of the system. Quantitative estimates make this point clearly. The annual flux of energy through
the body (~ 1,000,000 kcal/y) is enormous compared with the typical change in energy content of the body (< 2.5
lb, or 10,000 kcal/y). This represents an "error" of less than 1% with regard to the balancing of intake and
expenditure.
Why is relative weight stability the rule? To answer this question, it is useful to perform a thought experiment.
Consider what would happen if a person in energy balance simply added a cup of ice cream (500 kcal) to the diet
every night and kept everything else exactly the same (activity, other food intake). Would the person gain 3500
kcal (about 0.45 kg) of weight and fat every week for the rest of his or her life (ie, 227 kg after 10 years)? The
answer is no. The physiologic reason is that weight gain or loss results in increases or decreases, respectively, in
total energy expenditure (TEE). Thus, the energy balance system is adaptive (dynamic), not fixed. Moreover, the
changes in TEE can be extremely large in response to changes in body weight. It is now well documented that
adaptations of TEE to altered body weight are greatly in excess of what would be quantitatively predicted from
standard energy costs of tissues calculated in weight-stable humans, whether obese or nonobese. Recent studies
in humans by Leibel and colleagues make it possible to calculate the consequences on TEE of gaining or losing
weight. If a person gains 10% of body weight by overeating (ie, 712 kg in nonobese or obese subjects), about
two-thirds of the gain will be as body fat (58 kg) and one-third (24 kg) as fat-free mass (FFM). FFM, or lean
body mass (LBM), is the main determinant of resting energy expenditure (REE; see below) and also affects TEE;
the relationship is generally about 4550 kcal TEE/kg FFM per day both in obese and in nonobese individuals. A
10% weight gain would, therefore, be expected to increase TEE by 100200 kcal/d. Conversely, a 10% weight
loss consists of about 80% fat and 20% FFM (23 kg), so that the expected reduction in TEE would be 100150
kcal/d (23 kg FFM x 50 kcal/kg FFM/d).
But in fact, after stabilization at a 10% weight gain, increases in TEE are much greater than these values. TEE
increases by 870 kcal/d (Table 213). Accordingly, there is a change in the relationship between TEE and FFM;
the ratio of calories spent to FFM increases from 4550 to 5560 kcal TEE/kg FFM per d. Carrying the extra
weight (or fat) apparently changes the energy costs of all tissues rather than just adding energy costs of new
tissue. Change in REE appears to account for only a minority (~ 150 kcal/d) of the increased TEE; most of the
TEE increase (500700 kcal/d) relates in some manner to costs of activity. Conversely, a stable 10% weight loss
reduces TEE by 450550 kcal/d; the relationship between TEE and FFM now falls to about 40 kcal/kg FFM/d
(Table 213). In this direction, lower REE accounts for about half of the change in TEE.
Figure 214.

Metabolic mechanisms by which surplus carbohydrate intake leads to

body fat accrual by suppressing dietary fat oxidation rather than by
conversion of carbohydrates into fats (CHO, carbohydrate; DNL, de
novo lipogenesis; HGP, hepatic glucose production; ox, oxidation; INS,
insulin). "?" refers to signal of surplus CHO in organism (not proven, but
likely an increase in hepatic glycogen stores).