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Use of Body Fatness Cutoff Points–Reply–I

      We appreciate Dr Snitker's interest in our recent editorial
      • Lavie CJ
      • Milani RV
      • Ventura HO
      • Romero-Corral A
      Body composition and heart failure prevalence and prognosis: getting to the fat of the matter in the “obesity paradox.”.
      and his insightful comments regarding body fat (BF) and obesity. Additionally, we are aware of his clinical and research efforts in the area of obesity in children at the University of Maryland School of Medicine. Dr Snitker is correct that currently there is no definitive cutoff for percent BF in defining overweightness or obesity in men or women. In our efforts to simplify the message for readers, we referenced an easily accessible National Institutes of Health (NIH) publication
      • US Department of Health and Human Services
      • National Institutes of Health
      Understanding adult obesity. WIN Weight-control Information Network: National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Web site. NIH Publication No. 06-3680.
      that we thought was representative. Generally, we have referenced a major source from the World Health Organization (WHO)
      Physical status: the use and interpretation of anthropometry: report of a WHO expert committee.
      as opposed to this simple NIH Web site in our research publications from Ochsner Clinic
      • Lavie CJ
      • Milani RV
      • Artham SM
      • Patel DA
      • Ventura HO
      The obesity paradox, weight loss, and coronary disease.
      and Mayo Clinic.
      • Romero-Corral A
      • Somers VK
      • Sierra-Johnson J
      • et al.
      Diagnostic performance of body mass index to detect obesity in patients with coronary artery disease.
      • Romero-Corral A
      • Somers VK
      • Sierra-Johnson J
      • et al.
      Accuracy of body mass index to diagnose obesity in the US adult population.
      However, we agree with Snitker that, regardless of the reference, there is no criterion standard for defining overweightness or obesity by the BF method.
      We previously demonstrated in a cross-sectional design of 13,601 participants (age, 20-80 years; 48% men) from the Third National Health and Nutrition Examination Survey (NHANES III)
      • Romero-Corral A
      • Somers VK
      • Sierra-Johnson J
      • et al.
      Accuracy of body mass index to diagnose obesity in the US adult population.
      that the mean ± SD body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) in men was 26.6±4.6 and the mean ± SD percent BF was 24.8%±6.0%. Corresponding values in women were 27.6±6.4 and 36.7%±7.4%, respectively. In 6171 participants in NHANES III who had a BMI in the reference range (18.5-24.9), the highest tertile of BF was greater than 23.1% in men and greater than 33.3% in women (labeled as normal weight obesity).
      • Romero-Corral A
      • Somers VK
      • Sierra-Johnson J
      • et al.
      Normal weight obesity: a risk factor for cardiometabolic dysregulation and cardiovascular mortality.
      In this cohort with normal weight obesity defined by elevated BF, the prevalence of metabolic syndrome was 4 times higher than in those with low BF, and these individuals had a higher prevalence of dyslipidemia (men and women) and of hypertension (men) and a 2.2-fold increased risk of cardiovascular (CV) mortality (women) compared with those with low BF. These data suggest that this level of BF is associated with adverse CV risk and prognosis in primary prevention.
      In secondary prevention, having increased BF (>25% in men and >35% in women) appears to be associated with a protective effect in patients with coronary heart disease (CHD).
      • Lavie CJ
      • Milani RV
      • Artham SM
      • Patel DA
      • Ventura HO
      The obesity paradox, weight loss, and coronary disease.
      In fact, in patients with CHD
      • Lavie CJ
      • Milani RV
      • Artham SM
      • Patel DA
      • Ventura HO
      The obesity paradox, weight loss, and coronary disease.

      De Schutter A, Lavie CJ, Milani RV, Patel DA, Artham SM. Body composition and mortality in patients with coronary heart disease: the “obesity paradox.” Circulation. In press.

      and in those with heart failure,
      • Lavie CJ
      • Osman AF
      • Milani RV
      • Mehra MR
      Body composition and prognosis in chronic systolic heart failure: the obesity paradox.
      • Lavie CJ
      • Milani RV
      • Artham SM
      • Olivier AC
      • Ventura HO
      Does body composition impact survival in patients with advanced heart failure [abstract 1713].
      a higher BF was an independent predictor of event-free survival because of the obesity paradox, which we discussed in our editorial.
      • Lavie CJ
      • Milani RV
      • Ventura HO
      • Romero-Corral A
      Body composition and heart failure prevalence and prognosis: getting to the fat of the matter in the “obesity paradox.”.
      Oreopoulos et al
      • Oreopoulos A
      • Ezekowitz JA
      • McAlister FA
      The association between direct measures of body composition and prognostic factors in chronic heart failure.
      in their heart failure study used a Gallager classification of BF based on age, sex, and race and classified patients as underweight, normal, overweight, and obese.
      • Gallagher D
      • Heymsfield SB
      • Heo M
      • Jebb SA
      • Murgatroyd PR
      • Sakamoto Y
      Healthy percentage body fat ranges: an approach for developing guidelines based on body mass index.
      In preliminary data from our CHD population (n=581) using this Gallager classification, we have found the highest mortality in the underweight and lowest mortality in the overweight, who also had significantly lower mortality than the “normal BF” group during a 3-year follow-up (A.D.S, C.J.L, and R.V.M., unpublished observations, May 1, 2010). The obese group had intermediate mortality, which was significantly lower than the underweight and trended lower than the normal BF group but did not reach statistical significance.
      Therefore, current research suggests that the obesity cutoff points of BF are in the 23%-25% range in men and 33%-35% range in women (or 30% in women from the NIH,
      • US Department of Health and Human Services
      • National Institutes of Health
      Understanding adult obesity. WIN Weight-control Information Network: National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Web site. NIH Publication No. 06-3680.
      as Dr Snitker stated in his letter), which are associated with increased CV risk in primary prevention and reduced risk in patients with established CV disease (obesity paradox). However, we agree that additional research is needed to clearly define optimal BF in patients of both sexes and of various ages, races, and ethnic groups, as well as disease states. Clearly, major organizations such as the WHO, NIH, and major obesity societies should attempt to establish such cutoff points for BF, as was done years ago with BMI.

      REFERENCES

        • Lavie CJ
        • Milani RV
        • Ventura HO
        • Romero-Corral A
        Body composition and heart failure prevalence and prognosis: getting to the fat of the matter in the “obesity paradox.”.
        Mayo Clin Proc. 2010; 85: 605-608
        • US Department of Health and Human Services
        • National Institutes of Health
        Understanding adult obesity. WIN Weight-control Information Network: National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Web site. NIH Publication No. 06-3680.
        (Accessed September 29, 2010.)
      1. Physical status: the use and interpretation of anthropometry: report of a WHO expert committee.
        World Health Organ Tech Rep Ser. 1995; 854: 1-452
        • Lavie CJ
        • Milani RV
        • Artham SM
        • Patel DA
        • Ventura HO
        The obesity paradox, weight loss, and coronary disease.
        Am J Med. 2009; 122: 1106-1114
        • Romero-Corral A
        • Somers VK
        • Sierra-Johnson J
        • et al.
        Diagnostic performance of body mass index to detect obesity in patients with coronary artery disease.
        Eur Heart J. 2007; 28: 2087-2093
        • Romero-Corral A
        • Somers VK
        • Sierra-Johnson J
        • et al.
        Accuracy of body mass index to diagnose obesity in the US adult population.
        Int J Obes (Lond). 2008; 32: 959-966
        • Romero-Corral A
        • Somers VK
        • Sierra-Johnson J
        • et al.
        Normal weight obesity: a risk factor for cardiometabolic dysregulation and cardiovascular mortality.
        Eur Heart J. 2010; 31: 737-746
      2. De Schutter A, Lavie CJ, Milani RV, Patel DA, Artham SM. Body composition and mortality in patients with coronary heart disease: the “obesity paradox.” Circulation. In press.

        • Lavie CJ
        • Osman AF
        • Milani RV
        • Mehra MR
        Body composition and prognosis in chronic systolic heart failure: the obesity paradox.
        Am J Cardiol. 2003; 91: 891-894
        • Lavie CJ
        • Milani RV
        • Artham SM
        • Olivier AC
        • Ventura HO
        Does body composition impact survival in patients with advanced heart failure [abstract 1713].
        Circulation. 2007; 116: II_360
        • Oreopoulos A
        • Ezekowitz JA
        • McAlister FA
        The association between direct measures of body composition and prognostic factors in chronic heart failure.
        Mayo Clin Proc. 2010; 85: 609-617
        • Gallagher D
        • Heymsfield SB
        • Heo M
        • Jebb SA
        • Murgatroyd PR
        • Sakamoto Y
        Healthy percentage body fat ranges: an approach for developing guidelines based on body mass index.
        Am J Clin Nutr. 2000; 72: 694-701

      Linked Article

      • Use of Body Fatness Cutoff Points
        Mayo Clinic ProceedingsVol. 85Issue 11
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          To the Editor: In the July 2010 editorial of Mayo Clinic Proceedings, although correctly making the argument that “BMI [body mass index; calculated as weight in kilograms divided by height in meters squared] does not reflect true body fatness,” Lavie et al1 refer to the “National Institutes of Health [NIH] criterion standards” for percent body fat (BF) as greater than 25% in men and greater than 35% in women. The reference provided for this statement is a pamphlet2 for the general public, issued by the Weight Information Network (WIN), an NIH initiative to provide “science-based information on weight control, obesity, physical activity, and related nutritional issues.” Although I did not find any mention of body fat (BF) cutoff points in that publication, an earlier version3 did state that “Most health care providers agree that men with more than 25 percent body fat and women with more than 30 percent body fat are considered obese.” Note the discrepancy in cutoff for women between the editorial and the pamphlet.
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