3.

DEFINING OBESITY

Defining Obesity

Obesity is often defined simply as a condition of abnormal or excessive fat accumulation

in adipose tissue, to the extent that health may be impaired. However, obese individuals
differ not only according to the degree of excess fat, which they store, but also in the
regional distribution of the fat within the body. Indeed, excess abdominal fat is as great a
risk factor for disease as is excess body fat per se (WHO 1998).

3.1

Body Mass Index

One of the most commonly used indices of relative weight is the Body Mass Index
(BMI), which is defined as body weight in kilogram divided by height, in meters squared.
It was not originally intended as an index of obesity but is now commonly employed as
such in epidemiological studies, to predict obesity-related morbidity and mortality in
adults. A BMI of 30 kg/m2 is considered the threshold of obesity. BMI however, does not
distinguish between weight associated with muscle and weight associated with fat. BMI
can be considered to provide the most useful, albeit crude, population-level measure of
obesity. The classification of overweight and obesity in adults as proposed by WHO
(1998) is shown in Table 1.
Table 1: Classification of weight status in adults according to Body Mass Index (BMI)
Classification
Underweight
Normal range
Overweight:
Pre-obese
Obese class I
Obese class II
Obese class III

Source: WHO (1998)

BMI (kg/m2)
< 18.5
18.5 24.9
25
25 29.9
30.0 34.9
35.0 39.9
40.0

Risk of co-morbidities
Low (but risk of other clinical problems increased)
Average

Increased
Moderate
Severe
Very severe

The adequacy of the current international standard (WHO 1998) for informing policy and
interventions in some populations has been questioned due mainly to substantial interpopulation differences in the meaning of a given BMI (with respect to the level of body
fatness, the associated level of health risk, or both) and in the range of BMI itself.

There has been two previous attempts to interpret the WHO BMI cut-offs in Asian and
Pacific populations (WHO/IASO/IOTF 2000; James et al. 2002) A proposal has been
made to redefine the classification of obesity using BMI for Asian population (Table 2)
as there are now evidence that the increased risks of co-morbidities with obesity occurs
at a lower BMIs in Asians (WHO/IASO/IOTF 2000). The recommendation is however
based on two studies - in Hong Kong (Ko et al. 1999) and in Singapore (Deurenberg-Yap
et al. 2000).
7

Strategy for the Prevention of Obesity - Malaysia

Table 2: Classification of weight status according to BMI in Asian Adults

Classification
Underweight
Normal range
Overweight:
At Risk
Obese class I
Obese class II

BMI (kg/m2)
< 18.5
18.5 22.9
> 23.0
23.0 24.9
25.0 29.9
> 30.0

Source: WHO/IASO/IOTF (2000)

Risk of co-morbidities
Low (but risk of other clinical problems increased)
Average
Increased
Moderate
Severe

WHO convened another expert consultation in Singapore in 2002 to address the debate
on interpretation of recommended BMI cut-off points for determining overweight and
obesity in Asian populations.

The population level of BMI cut-off points is to identify risks of adverse health outcomes
associated with different levels of body composition, so as to inform and trigger policy
action, facilitate prevention programmes and to measure the impact of interventions. BMI
cut-off points are also used for epidemiological purposes to help in determination of the
aetiology of diseases. For clinical applications, population specific cut-off points will need
to be determined by countries as most appropriate and should be used with an individuals
clinical history and other clinical measurements (e.g. waist circumference and presence of
other related factors). Ethnic-specific cut-off points may not be useful as it is likely to
create great confusion in health promotion and disease prevention and management.

Rationale

It has become increasingly clear that there is an emerging high prevalence of noninsulin dependent diabetes (NIDDM) and cardiovascular risk factors in parts of Asia
below the cut-off points of less than 25 kg/m2 for overweight and BMI less than 30.0
for obesity. (Ko et al. 1999; Deurenberg 2001; China Obesity Task Force 2002; Yajnik
2002; Zhou 2002)

It is also known that relationship between BMI, and body fat percent and fat
distribution, are less favourable in many Asian populations compared with
Caucasian/European populations (Wang et al. 1994; Gurrici et al. 1998; DeurenbergYap et al. 2000; He et al. 2001).
The BMI cut-off points for observed increased risk in different Asian populations
varies from 22 to 25 kg/m2 and for high risk varies from 26 to 31 kg/m2 (Deurenberg
& Deurenberg-Yap 2003)
8

Defining Obesity

If BMI cut-off values for overweight and obesity were to be lowered, it will automatically
increase their prevalence rate overnight. This would then require adaptation in public
health policies and clinical management guidelines. It would, however, also increase the
governmental and public awareness and as such help to combat the increasing prevalence
of obesity.
The WHO Expert Consultation (2004) made no attempt to redefine BMI cut-off points
for each population based on the body composition data. Rather, the Consultation
identified potential public health action points along the continuum of BMI. Reasons
for this approach;

1) The relationship between BMI and risk curves are continuous, hence, all cut-off points
based on risk slope are arbitrary.

2) Epidemiology hard outcomes such as defined disease were considered better than
body composition and more meaningful to clinicians and policy makers.
3) BMI versus body composition varies substantially but the variation is not consistent
across populations and within a given population under different social and lifestyle
changes over time.

Recommendations (WHO Expert Consultation 2004)

1) The current WHO cut-off points of 18.5, 25, 30 and 40 kg/m2 are retained. But the cutoff points of 23, 27.5, 32.5 and 37.5 kg/m2 (Figure 1) are to be added as points for
public health action.

2) For continuity, particularly in countries with concurrent problems of undernutrition

and overnutrition, the distribution should continue to be presented as a continuum
beginning with BMI less than 16 kg/m2, through the BMI category of equal to or more
than 40 kg/m2. Above 18.5 kg/m2 the categories are simply midway between the
current cut-off points, except for the 18-24.9 kg/m2 category. In this latter case, the
intermediate cut-off point (23.0 kg/m2) was chosen as a public health action point on
the basis of the results of the meta-analysis from 9 countries in Asia and other
published work.

3) For many Asian populations, additional trigger points for public health action were
identified as 23 kg/m2 or higher, representing increased risk, and 27.5 kg/m2 or higher,
as high risk. The suggested categories are as follows: less than 18.5 kg/m2
underweight; 18.5-23 kg/m2 increasing but acceptable risk; 23-27.5 kg/m2 increased
risk; and 27.5 kg/m2 or higher, high risk.

Strategy for the Prevention of Obesity - Malaysia

Guidance should be provided to countries to identify public health action points that
are most useful for the situation in each country. Countries should be aware that the
increased risk is a continuum with increasing BMI, and that cut-off points are merely
a convenience for public health and clinical use. Consequently, ranges were given (see
Figure 1) but with the assumption that many Asian countries will use the ranges
suggested. However global definition of overweight and obesity would remain as 25
kg/m2 and above for overweight and 30 kg/m2 and above for obesity.

4) In considering BMIs of less than 21, it should be borne in mind that the lower range
of BMI might reflect undernutrition in populations with current or recent widespread
undernutrition.
5) Wherever possible, countries should use all categories for reporting purposes with a
view to facilitating international comparisons (i.e. 18.5, 20, 23, 25, 27.5, 30, 32.5
kg/m2, and in many populations, 35, 37.5 and 40 kg/m2)

6) Where possible, in populations with a predisposition to central obesity and related

increased risk of developing the metabolic syndrome, waist circumference should also
be used to refine action levels based on the basis of BMI. For example, action levels
based on BMI might be increased by one level if the waist circumference is above a
specified action level.

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Figure 1: Suggested cut-off points ( ) for reporting population BMI distribution

and specific action levels for population and individuals
Source: WHO (2004)

10

Defining Obesity

The recommendations above also suggests that the cut-off points for observed risks
among Asians varies by three BMI points and made no attempt to redefine cut-off points.
There is also lack of local data to support any changes to the BMI classification. The
Committee recommends retaining the current WHO classification of BMI (WHO 1998)
for adults (Table 1). However, the Committee acknowledges the need to have the public
health action points as recommended by WHO Expert Consultation 2004 (Table 3).
Table 3 : Recommended BMI cut-off points for body weight classification and
public health action for Malaysians
Body
BMI cut-off points
weight
for definition1
classification
(kg/m2)
Underweight
<18.5
Normal range
18.5 to 24.9
Overweight
25.0
Pre-obese
25.0 to 29.9
Obese class I
30.0 to 34.9
Obese class II
35.0 to 39.9
Obese class III
40.0

Comorbidities
risk
Low

Moderate
High
Very high

BMI cut-off points

for public health action2
(kg/m2)
<18.5
18.5 to 22.9
23.0 to 27.4
27.5 to 32.4
32.5 to 37.4
37.5

Source: 1WHO (1998); 2WHO Expert Consultation (2004)

3.2 Waist Circumference and Waist Hip Ratio

Excess abdominal fat is an independent predictor of risk factors and morbidity of obesityrelated diseases such as type 2 diabetes, hypertension, dyslipidaemia and cardiovascular
diseases. Waist circumference is positively correlated with abdominal fat. Hence, waist
circumference is a valuable additional alternative method in identifying individuals at
increased risk. Waist circumference (WC) is a convenient and simple measurement
(Figure 2), which is unrelated to height and correlates closely with BMI and Waist-Hip
Ratio (WHR). It is an approximate index of intra-abdominal fat mass.
Populations differ in the level of risk associated with a particular waist circumference, and so
global cut-off points cannot be applied. For Caucasians, waist circumference of 94 cm and
above in men and 80 cm and above in women denotes increased risk while waist circumference
of 102 cm and above in men and 88 cm and above in women denotes substantially increased
risk of metabolic complications (WHO 1998). WHO/IASO/IOTF (2000) report suggested cut
off points of 90 cm and above in men and 80 cm and above in women.
However, it has become increasingly clear that there is a high prevalence of type 2
diabetes mellitus and cardiovascular risk factors in parts of Asia below these cut off
points. Evidence from several Asian countries is now available including Hong Kong (Ko
et al. 1999), Singapore (Deurenberg 2001) and China (China Obesity Task Force, 2002;
11

Strategy for the Prevention of Obesity - Malaysia

Zhou 2002; Jia et al. 2002). Thus based on the current evidence, the WHO/IASO/IOTF
(2000) proposed waist circumference cut-off points are adopted (Table 4).
Table 4: Waist circumference cut-off points for increased risk to metabolic diseases
WHO (1998)
WHO/IASO/IOTF (2000)

Men
94cm (37 inches)
90cm (35 inches)

Women
80cm (32 inches)
80cm (32 inches)

Over the last decade, a high WHR (WHR more than 1.0 in men and more than 0.85 in
women) has become accepted as the clinical method of identifying patients with
abdominal fat accumulation. However, recent advances suggest that waist circumference
alone is a better and more practical measure.

Figure 2: Measuring Waist Circumference

12

REFERENCES

Defining Obesity

China Obesity Task Force. (2002). Predictive value of body mass index and waist
circumference to risk factors of related diseases in Chinese adult population. Clinical
Journal of Epidemiology. 23:5-10.

Deurenberg P. (2001). Universal cut-off BMI points for obesity are not appropriate.
British Journal of Nutrition. 85:135-136.
Deurenberg P & Deurenberg-Yap M. (2003). Validity of body composition methods
across ethnic population groups. In: Elmadfa I, Anklam E, Konig JS. Eds. Modern
aspects of nutrition: present knowledge and future perspective. Forum Nutr. Basel
Karger. 56:299-301

Deurenberg P, Deurenberg-Yap M, Wang J, Lin FP & Schmidt G. (1999). The impact of

body build on the relationship between body mass index and body fat percent.
International Journal of Obesity. 23:537-542

Deurenberg-Yap M, Schmidt G, Staveren WA & Deurenberg P. (2000). The paradox of

low body mass index and high body fat percent among Chinese, Malays and Indians
in Singapore. International Journal of Obesity. 24:1011-1017.

Gurrici S, Hartriyanti Y, Hautvast JG & Deurenberg P. (1998). Relationship between

body fat and body mass index: differences between Indonesians and Dutch
Caucasians. European Journal of Clinical Nutrition. 52(11):779-83.

He M, Tan KCB, Li ETS & Kung AWC. (2001). Body fat determinations by dual energy
X-ray absorptiometry and its relation to body mass index and waist circumference in
Hong Kong Chinese. International Journal of Obesity. 25:748-752.

James WPT, Chen C & Inoue S. (2002). Appropriate Asian body mass indices? Obesity
reviews. 3(3):139

Jia WP, Xiang KS, Chen L, Lu JX & Wu YM. (2002). Epidemiological study on obesity
and its comorbidities in urban Chinese older than 20 years of age in Shanghai, China.
Obesity Reviews. 3(3):157-165.
Ko GTC, Chan JC, Cockram CS & Woo J. (1999). Prediction of hypertension, diabetes,
dyslipidaemia or albuminuria using simple anthropometric indexes in Hong Kong
Chinese. International Journal of Obesity. 23:1136-1142.

Wang J, Thornton JC, Russell M, Burastero S, Heymsfield SB & Pierson RN. (1994).
Asians have lower BMI but higher percent body fat than do Whites: comparisons of
anthropometric measurements. American Journal of Clinical Nutrition. 60:23-28.
13

Strategy for the Prevention of Obesity - Malaysia

WHO. (1998). Obesity: Preventing and managing the global epidemic. Report of a WHO
Consultation on Obesity. Geneva: World Health Organisation.

WHO Expert Consultation. (2004). Appropriate body mass index for Asian populations
and its implication for policy and intervention strategies. Lancet. 363:157-163

WHO/IOTF/IASO. (2000). The Asia-Pacific perspective: Redefining Obesity and its

Treatment. Hong Kong: World Health Organization, International Obesity Task Force,
International Association for the Study of Obesity.
Yajnik CS. (2002). The lifecycle effects of nutrition and body size on adult adiposity,
diabetes and cardiovascular disease. Obesity Reviews. 3(3):217-224.

Zhou BF. (2002). Predictive values of body mass index and waist circumference for risk
factors of certain related diseases in Chinese adults-study on optimal cut-off points of
body mass index and waist circumference in Chinese adults. Biomedical and
Environmental Sciences. 15:83-95.

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