Fad Diets and Obesity

Part I: Measuring Weight

In a Clinical Setting
Mark A. Moyad

besity is as an epidemic
in the United States and
other industrialized countries (National Heart,
Lung, and Blood Institute [NHLBI],
1998). The overall prevalence of
obesity (body mass index [BMI] of
30 or more) continues to increase
at a dramatic pace. An increase
in the obesity rate of 15% to 27%
of Americans has occurred in just
the past 20 years (Department of
Health & Human Services, 2001).
In addition, nearly 66% of
Americans are overweight (BMI
25-29). Approximately 325,000
deaths and $39 to $52 billion in
health care costs have been
attributed to obesity annually
(Flegal, Carroll, Ogden, &
Johnson, 2002). Obese individuals have a greater risk of early
mortality versus the nonobese,
especially from cardiovascular
disease (NHLBI, 1998; Singh &
Lindstead, 1998; Solomon &
Manson, 1997). For example,
some studies have found as
much as a seven-fold increase in
coronary heart disease with a
BMI of 35 or greater (Ellis, Elliott,
Horrigan, Raymond, & Howell,
1996). Obesity is also associated

Mark A. Moyad, MPH, is the Phil F.

Jenkins Director of Complementary/
Preventive Medicine, Urologic Oncology,
University of Michigan Medical Center,
Department of Urology (Section of
Urology), Ann Arbor, MI.

114

Obesity is a recognized epidemic in many regions around the world

and billions of dollars are spent each year in attempting to combat
this problem. However, before a discussion of the different conventional and alternative treatments for obesity can be initiated, it is first
critical to determine whether or not a certain individual is actually
overweight, obese, or has an excess of adipose tissue. Therefore, a
review of the various popular and unpopular measurements of obesity is needed. A variety of measurements exist such as bioelectrical
impedance, body mass index (BMI), crude weight, densitometry, dual
energy x-ray absorptiometry (DEXA), lean body mass (LBM), skinfold
thickness, and waist-to-hip ratio (WHR). All of these measurements
contain inherent advantages and disadvantages, but many of these
can still be used in a clinical setting. Health professionals should
acquaint themselves with these different measurements in order to
take the first step in bringing attention to and potentially treating a
condition that affects virtually every medical discipline.

with many co-morbid conditions

such as dyslipidemia, heart disease, hypertension, type 2 diabetes, osteoarthritis, gallbladder
disease, and a variety of cancers
(Ellis et al, 1996; NHLBI, 1998;
Quesenberry, Caan, & Jacobson,
1998). This list of co-morbid conditions seems to grow with each
passing decade, and a brief summary of some of these conditions
is listed in Table 1 (Moyad,
2002).
Multiple treatment strategies
seem to be the general approach
to managing obesity. Several of
these strategies will be discussed
in later manuscripts of this series
including lifestyle changes, drug
intervention, and surgery. Surveys
have indicated that about onethird of U.S. adults are attempting

to lose weight, and another third

are trying to maintain weight, and
in many cases these attempts are
unsuccessful (Serdula et al.,
1999). Therefore, for health professionals to enhance their knowledge about obesity and the issues
surrounding this subject, it
seemed important to provide a
series of reviews that cover the
various aspects of the obesity
debate. In the first part of the
series the various measurements
that can and cannot be used in a
clinical setting will be covered.
Other parts of this series will not
only cover conventional treatment options, but other methods
of attempting weight loss such as
the various fad diets the health
professional has and will be dealing with in the future. Again, this

UROLOGIC NURSING / April 2004 / Volume 24 Number 2

Table 1.
A Partial Alphabetical List of Potential Conditions
Associated with Obesity
Benign prostatic hyperplasia (BPH)
Cancer (breast, cervical, colorectal, endometrial, gallbladder, kidney,
prostate)
Cataracts
Coronary artery disease
Dyslipidemia
Diabetes
Erectile dysfunction
Gallbladder disease
Gout
Gastroesophageal reflux disease (GERD)
Hypertension
Osteoarthritis
Respiratory compromise
Sleep apnea

series of articles should provide a

strong foundation for health professionals who will continue to
deal with these issues.

Defining Overweight
And Obesity
Obesity is generally defined
as an excess concentration of
body fat or adipose tissue.
Obesity and overweight are terms
often used interchangeably, but
they do not necessarily represent
the same situation. Some individuals may be overweight but
not obese, while obese individuals are overweight to a certain
defined degree.
Adipose tissue or storage fat
and lean tissue are two of the primary compartments of the
human body. Adipose tissue is
generally regarded as metabolically inactive in terms of energy
and nutrient requirements, and
its primary energy needs are for
cargo transportation from one
location to another. Adipose tissue consists mainly of storage fat,
mostly in the form of triglyceride, which is one of the reasons
that individuals who lose fat generally experience an adequate
reduction in their serum values
of triglycerides. On the other
hand, when someone gains a significant amount of adipose tissue, especially in the abdominal
area, his or her triglyceride level
may increase. Again, adipose tissue is less metabolically active,

but it does have a major role in

hormone metabolism (for example, in the synthesis of estrogen
in postmenopausal women)
(Grodin, Sitteri, & MacDonald,
1973), which is one of the main
reasons that obese individuals
generally tend to not only have
higher bone mineral densities,
but also a lower risk of osteoporosis and fractures. The storage of fat occurs primarily
beneath the skin and in the
abdominal area, but fairly large
concentrations are also found
within muscles and surrounding
other organs such as the heart or
kidneys.
Lean tissue is involved in
active metabolic pathways, so
that nutritional requirements are
primarily related to the overall
size of this area. This tissue is
generally considered the area of
the body that is not made up of
adipose tissue, so it can be very
heterogeneous in nature. It consists mainly of muscle, bone,
extracellular water, nervous tissue, a variety of organs, and all of
the cells that are also not adipose. If the lean body mass is
measured, the adipose concentration can be calculated as the
difference between the lean and
total body areas. Generally dividing the human body into adipose
and lean body mass is a simple
and easy anatomic perspective to
understanding some anthropometric variables. Although, adi-

UROLOGIC NURSING / April 2004 / Volume 24 Number 2

pose tissue does not include all

of the fat in the body, such as the
lipid contained within cells,
hepatocytes, or other significant
structural lipids in cell membranes or the nervous system.
Thus, it may be more suitable at
times to divide the body on the
basis of chemical composition,
rather than anatomy, between fat
mass and fat-free mass areas.
These areas correspond closely,
but not precisely, to adipose and
lean body mass. This distinction,
however, is not of any major
practical importance because
lipid composes only approximately 2% of the lean body mass
(Sheng & Huggins, 1979).

Methods Used to Clinically

Measure Weight (From A-Z)
Defining obesity is not a difficult task, but measuring obesity
can be difficult, controversial,
and presents the health professional with numerous other challenges depending on the method
used. Currently, no universally
agreed upon, cheap, simplistic,
accurate, and reproducible measurement of obesity is available.
Each anthropometric measurement or parameter contains
inherent advantages and disadvantages. Numerous methods of
measurement are generally used
to measure obesity and these are
covered in the rest of the manuscript in alphabetical order for
simplicity.

Bioelectrical Impedance
Analysis
Bioelectrical
impedance,
conductance, or resistance measurements to determine lean
body mass and body fat composition, or the percent body fat, are
popular. The thought behind this
test is that lean body mass, which
contains mostly ions in a water
solution, can conduct electricity
to a greater degree than fat tissue
(Baumgartner, 1996). The resistance of the human body to an
electrical current is inversely correlated with the lean body mass,
so that the greater the electrical
resistance, the less the body concentration of lean tissue, and the
less the resistance the greater the

115

amount of lean tissue. If the total

body mass has been established,
than the fat mass and percentage
of body fat can be calculated.
Body shape can also affect the
resistance, so this must be considered in the final calculations.
Bioelectrical impedance measurement procedures are not difficult to perform. Generally two or
four electrodes are placed on an
individuals extremities while the
person is clothed and recumbent.
A small radio frequency signal is
applied to the electrodes, and
than the impedance or resistance
can be measured. Generally, several measurements are taken, but
the entire procedure takes less
than 1 minute. The actual signal
generator and recording device is
small in size and portable, but it
can be expensive. Electrical resistance measurements are easier
and more rapid than other expensive measurements such as densitometry, which will be discussed later. More research is
needed in the future to see if this
procedure will have any role in
future epidemiologic and clinical
investigations.

Body Mass Index (BMI)

Also Known as Quetelets
Index
BMI is one of the better methods to determine who is potentially overweight or obese
(Kuczmarski, Carroll, Flegal, &
Troiano, 1997). It can be performed rapidly in the clinical setting just by measuring the weight
and height of the individual. It is
best not to have the patient selfreport his or her weight and
height because this lacks accuracy. However, the definition of
overweight and obesity in relation to BMI may differ slightly
according to different medical
organizations.
BMI is defined as the weight
(in kilograms) divided by the
square of the height in meters
(kg/m2). Another method of
determining BMI is to take the
weight of the patient in pounds
and divide this number by the
square of the height in inches,
and to multiply this value by 704
(pounds/inches2 x 704) (Moyad,

116

2003). A BMI less than 25 is considered normal by the World

Health Organization, while 25 to
29.9 is overweight, and 30 or
greater is defined as obese. There
are three classes of obesity: Class
I is a BMI of 30 to 34.9 kg per m2,
Class II is a BMI of 35 to 39.9, and
Class III is a BMI equal or greater
than 40. There has been a substantial increase in the prevalence of all three of these obesity
classes over the past decade.
Most statistics reported in the
media on the percentage of overweight and obese individuals in
a population actually are derived
from medical studies that use the
BMI as a measurement. BMI is
arguably the most widely reported current measurement of obesity in medical studies. Some organizations define a BMI of 35 or 40
or more as morbidly obese and
these are the BMIs that are generally needed in order to qualify
for more serious conventional
medical therapy such as gastric
bypass surgery if no other treatments have been helpful.
BMI does not take into
account more muscular frames at
different heights, as is the case
with measuring crude weight
(mentioned later in the article).
Thus, a patient who lifts weights
or engages in resistance exercises
may actually experience a slight
increase in BMI due to an
increase in lean body mass
which weighs more than fat tissue. However, patients with BMI
values equal to or greater than 30
generally have an excess of adipose tissue.

Crude Weight
Measuring crude weight is
most likely the simplest method
to determine obesity (Najjar &
Rowland, 1987). Mild obesity is
defined as 20% to 40% overweight. Moderate obesity is 41%
to 100% overweight. Severe obesity is a weight greater than twice
the actual weight for a standard
or specific height. Crude weight
does not adjust for more muscular frames at different heights,
because it is as simple as getting
on a scale and measuring the
value.

Densitometry
Densitometry is also known
as hydrostatic weighing and
has been one of the past standard
measurements used for several
decades (Going, 1996). It is based
on the finding that adipose tissue
does not weigh as much as fatfree tissue. The ratio of weights
measured in air and under water
can provide a prediction of the
percentage of total body mass
that is made up of fat tissue. The
most popular method involves
wearing a swimming suit. The
individual sits on a scale and is
briefly submerged in a tank of
water. A weight is also attached
to the body so the individual is
not able to float. Residual lung
volume is also measured by having the subject breathe through a
snorkel into a device. This volume must be measured because
the air in the lungs can affect precise weight measuring under
water. When the data are
obtained, the percentage of body
fat can be calculated using a
mathematical formula (Brozek,
Grande, Anderson, & Keys, 1963;
Siri, 1961). A variation in the
water amount of the lean body
mass, bone size, and in the density of bone are generally the primary sources of error (Lohman,
1981; Lukaski, 1987).
Errors of 3% to 4% have
occurred with this method. The
primary disadvantage of this
method is the cost and time it
takes to measure this parameter.
This does not make it a useful
approach for large-scale studies,
and in terms of precision, the
dual energy x-ray absorptiometry
scan is beginning to replace this
older method of measurement.

Dual Energy X-ray

Absorptiometry (DEXA)
DEXA uses an x-ray beam
with two energy peaks (high and
low) in combination with a
whole body scanner. It was
invented in the 1980s to measure
bone mass and has also been
used to measure soft tissue body
composition (Lohman, 1996;
Roubenoff, Kehayias, DawsonHughes, & Heymsfield, 1993).
This method is able to differenti-

UROLOGIC NURSING / April 2004 / Volume 24 Number 2

ate fat mass, fat-free mass, and

bone mineral mass for the total
body and for specific anatomic
regions through the differential
absorption of the high and lowenergy x-rays by these various
tissues. The total radiation dose
is low (approximately 10% of the
radiation of a basic chest x-ray)
(Moyad, 2003); therefore, this
method can be used for all age
groups with the notable exception of pregnant women. This is
an easier method for individuals
than measuring densitometry.
However, the x-ray and the scanning device itself are not cheap
and the appropriate software and
certified operator must be used.
DEXA scans seem to be better
known for their potential to
determine the risk for osteoporosis (Genant et al., 1996).
Currently, it is the gold standard
for measuring bone mineral density and screening for osteoporosis in women and men.
Regardless, the DEXA scan is
also currently being used to measure fat composition, and its
reproducibility and accuracy are
quite good. Whether or not it is
more accurate than densitometry
remains to be investigated.
Again, its biggest limitation and
the reason it will probably not
gain widespread acceptance for
several more years in epidemiologic and clinical studies is due
to the cost. However, in the near
future it is possible that in a matter of minutes, a patient can have
his or her bone mineral density
and adipose tissue concentrations measured simultaneously
and for a lower cost.

Lean Body Mass (LBM)

LBM is a unique method of
measurement. It is simply a calculation of the body sites that are
not composed of adipose tissue,
and are more metabolically
active. LBM is predicted by using
a complex and imperfect equation (Sheng & Huggins, 1979;
Watson, Watson, & Batt, 1980).
For example, one of the more
common methods to calculate
LBM in some clinical studies is
to use the following equation:
2.447 - 0.09516 age (years) +

0.1074 height (cm) + 0.3362

weight (kg) divided by 0.732. A
greater LBM should correlate
with less obesity or fat tissue,
although universal agreement on
its accuracy remains to be decided. This is primarily due to population or ethnic differences,
which can vary substantially.
The equation also theorizes, perhaps incorrectly, that the percentage of water in an individuals
LBM
is
constant.
Regardless, it is a rapid way of
generally accessing lean body
mass in individuals from epidemiologic studies.

Skinfold Thickness
(Skin Calipers)
Skinfold measurement has
been the most popular method to
measure body composition in
epidemiologic studies apart from
combinations of weight and
height, such as BMI. A skin
caliper is needed to measure
skinfold thickness or to determine adipose tissue amounts.
This method has been appealing
because it provides a direct measure of body fat. However, it is
limited because not all body fat is
accessible to the calipers, such as
intra-abdominal and intramuscular fat, and the distribution of
subcutaneous fat can vary significantly over the human body
(Bellisari, Roche, & Siervogel,
1993; Rosenbaum, Leibel, &
Hirsch, 1997). The subcutaneous
fat variability can be a problem
when measurements at one or
several sites are used to represent
overall body fat composition.
These measurements overall are
substantially less reproducible
than most other anthropometric
measurements (Bray et al., 1978;
Lukaski, 1987).
Past investigations of the
variation in skinfold measurements have revealed the problems with this method of measurement. For example, one
study observed that a small difference of only 2.5 cm in the site
of measuring the triceps skinfold
actually resulted in a difference
as great as 50% in the average
skinfold (Ruiz, Colley, &
Hamilton, 1971). Other factors

UROLOGIC NURSING / April 2004 / Volume 24 Number 2

were subject to less variation,

such as the manner in which the
skinfold was grabbed and picked
up and the depth of the caliper
bite. In combination, these factors contribute to the significant
inter-observer variation that is
usually reported for these measurements. Additionally, this
potential for consistent error
does not allow skinfold measurements to be of any substantial use
when following weight changes
or obesity over time (Bray et al.,
1978). This method is cheap and
fairly easy to perform, but again
overall health professionals have
not found this method accurate
or necessarily useful primarily
because it cannot accurately
measure abdominal or central
obesity (Bellisari et al., 1993;
Rosenbaum et al., 1997).
Several investigations have
suggested that truncal obesity
may have a greater correlation to
carbohydrate and lipid metabolism disorders and hypertension
compared to peripheral obesity
(Blair, Habicht, Sims, Sylwester,
& Abraham, 1984). The use of triceps and subscapular skinfolds
seems to be based on past protocols and convenience; however,
it is possible that skinfold measurements at other body sites
may provide a better evaluation
of obesity in the extremities or
trunk and of disease risk (Roche,
1984). Thus, the best measuring
site for the specific condition
being studied needs further
investigation.

Waist-to-Hip Ratio (WHR)

WHR may be another simple
method to measure obesity, and
the subject is required to stand
during the entire measurement.
WHR more specifically measures
abdominal adipose tissue (circumference) and fat distribution
(Cox & Whichelow, 1996). The
waist is simply defined as the
largest abdominal circumference
midway between the costal margin and the crest of the iliac. The
largest circumference just below
the iliac crest is defined as the
hip. A WHR in women greater
than 0.80, and in men greater
than 0.90, is a fairly accurate pre-

117

dictor of an increased risk of obesity-related conditions, which is

actually independent of BMI
(Gray & Fujioka, 1991; Solomon,
& Manson, 1997). Individuals
with excess abdominal (visceral)
fat demonstrate a variety of metabolic changes such as insulin
insensitivity and increased freefatty acid production versus
those whose fat is mainly distributed subcutaneously over the
lower-body extremities (Bjorntorp,
1987). These metabolic differences
provide the foundation for evaluating the risk of disease in relation to
adipose distributions (Lapidus et
al., 1984). The accuracy in measuring WHR is slightly greater in general for men than women (Seidell
et al., 1987).
Postprandial status, standing
position, time of day, and even the
depth of inspiration can also
affect this parameter. The degree
to which these factors can contribute to error is unknown.
Additionally, abdominal circumference includes tissue from both
intra-abdominal and subcutaneous fat. Since intra-abdominal
tissue is the area of interest, just
how to correct for the level of subcutaneous tissue is also unknown.
WHR (along with other anthropometric parameters) still must be
validated in different ethnic
groups, as is the case with similar
newer measurements such as
waist-to-thigh and waist-to-height
ratio (Ko, Chan, Cockram, & Woo,
1999). Regardless, it is not unusual to measure the BMI and WHR
together in one clinical visit and
to make these and other parameters a permanent part of the
patients clinical record.

Conclusion
Before health professionals
can begin consulting the patient
on various methods to lose or
maintain weight, the precise distribution of adipose tissue and
whether or not the patient is truly
overweight or obese must be accurately determined. Therefore, this
manuscript should provide the
health professional with a fairly
strong foundation into the advantages and disadvantages of using a
variety of weight measurements

118

Table 2.
A Partial Summary (From A-Z) of the Advantages and
Disadvantages of a Variety of Obesity
Measurement Methods
Method

Advantage

Disadvantages*

Bioelectrical impedance

Rapid, easy to measure,

and portable device.

Equipment is expensive
in many cases.

Body mass index (BMI)

Simple, inexpensive, and

should be measured in
most clinical settings.

An increase in muscular
tissue can falsely elevate
this value.

Crude weight

Simple and inexpensive.

Does not take into

account the height and/
or increase in muscular
mass of the patient.

Densitometry
(hydrostatic weighing)

Accurate past method of

measuring fat tissue
concentrations.

Cost and time

make it less useful in
current clinical and
epidemiologic studies.

DEXA

Accurate current
assessment of fat tissue
and the gold standard for
osteoporosis screening.

Cost is the biggest issue,

and a certified operator
and new software are
needed.

Lean body mass

Most calculations are

easy and just require the
individuals age, height,
and weight.

Assumes a complex
formula fits for a population, and more muscular
frames are not taken into
account.

Skinfold thickness
(skin calipers)

Simple, cheap, and easy

to perform at many sites.

Poor measurement
of abdominal adipose
tissue.

Waist-to-Hip ratio (WHR)

Fairly accurate assessment of abdominal obesity and all that is needed

is a tape measure.
Should be measured in
most clinical settings
along with BMI.

Intra-abdominal tissue
(area of interest) is
difficult to differentiate
between subcutaneous
tissue and measurement
can be affected by the
individuals postprandial
status, depth of
inspiration, standing
position, etc.

*Note: All of the above listed anthropometric parameters need further

research in a variety of ethnic groups.

in the clinical setting. A quick

review of the advantages and disadvantages of some of the past
and current measurement parameters of obesity are summarized
in Table 2.
Discussing and using various
measurements of obesity or
weight must be a priority for the
health professional not only
because the majority of the population are affected by this epidemic, but because of the numerous health conditions and early
overall mortality clearly associated with obesity. In addition,

ongoing and recent research continues to find that many other

conditions, apart from obesity
itself, and even the recurrence of
some diseases are dramatically
increased in obese patients after
conventional treatment.
Cancer, cardiovascular disease, osteoarthritis, gout, etc; it
seems that few diseases and medical disciplines today are not
affected by obesity, and this is
one of the primary reasons health
professionals must make measuring and treating this condition an
absolute priority.

UROLOGIC NURSING / April 2004 / Volume 24 Number 2

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Additional Reading
Freedland, S.J., Aronson, W.J., Kane, C.J.
Presti, J.C. Jr., Amling, C.L., Elashoff,
D., & Terris, M.K. (2004). Impact of
obesity on biochemical control after
radical prostatectomy for clinically
localized prostate cancer: A report by
the Shared Equal Access Regional
Cancer Hospital Database Study
Group. Journal of Clinical Oncology,
22(3), 446-453.

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