LÍNEA DE TRANSMISIÓN MANTARO – NUEVA YANANGO Y

Obesity can be identified by using different measures such as Body Mass Index (BMI), Waist Circumference (WC), skin fold thickness-biceps, triceps, subscapular, suprailiac, Dual energy and X-Ray absorptiometry, Computed Tomography (CT) and Magnetic Resonance Imaging scan (MRI). The most common definition of obesity used was based on BMI (Burkhauser and Cawley, 2008). This section will discuss the classification of obesity and its measurement, causes of obesity, inequalities and stigma of obesity, health effects of obesity and strategies for tackling obesity. Finally, obesity and women’s health will be discussed.

BMI is determined by calculating a person's weight in kilograms divided by height in meters squared. Most literature suggests that an individual with a BMI of 30 or more is regarded as obese. Based on BMI, obesity can be further subdivided into: class I obesity with a BMI range between 30 to 34.9, class II obesity having a BMI range of 35-39.9 and class III or morbid obesity characterised with a BMI of 40 and above (Despres, 2012; WHO, 2003). In most research, BMI is used as a tool for assessing obesity, with evidence

suggesting individuals with a high BMI level have adverse health outcomes compared to the non-obese (Andreasen,, Andersen, & Schantz, 2004; Burkhauser and Cawley, 2008;). BMI is widely used around the word so the researcher could compare data obtained with that published. Aronne and Louis (2002) confirmed that this method of measurement is easy and quick to use in busy clinical areas, because it only requires height and weight measurement for calculation (Shugart et al., 2009). In addition, BMI tends to be used in health care settings when planning care packages (Aronne and Louis, 2002).

Even though BMI is easy to calculate, (Shugart et al., 2009), it is challenged as a suitable indicator of obesity (Scafoglieri et al., 2013; Despre´s, 2012; Shugart et al., 2009; Rees et al., 2008; Burkhauser and Cawley, 2008). According to Flegal et al. (2010), BMI is significantly affected by age, gender and ethnicity and there needs to be adjustments made for these factors. Therefore, BMI may give false results. Specifically, it can over-estimate body fat among professional athletes or under-estimate body fat among elderly persons who have lean muscles (Rees et al. 2008), and does not distinguish between fat-free mass, like bone and muscles, with fat (Burkhauser and Cawley, 2008). Furthermore, BMI does not discriminate between visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT) (Scafoglieri et al, 2013) and research has shown that storing fat around the waist (in visceral adipose tissue; VAT) is more dangerous for individual health than around the thighs and legs (in subcutaneous adipose tissues; SAT). However, BMI cannot measure both SAT and VAT, since fat cells actually regulate metabolic functions, and expert opinion is that fat cells in the belly release large amounts of fatty acids, which can destroy and increase blood sugar and insulin metabolism in the body (Woolston, 2016). Burkhauser and colleague (2008) discouraged the use of BMI and proposed the use of

other techniques such as waist circumferences and waist to hip ratio (Burkhauser and Cawley, 2008).

Waist circumference (WC) and waist to hip ratio are regarded as the best indices for assessing abdominal obesity. Both are designed to measure fat distribution throughout the body, especially around the abdomen (Scafoglieri et al., 2013). The rationale behind the use of WC is related to its accuracy for measuring visceral adipose tissues (VAT) (Berentzen et al., 2012). Waist circumferences can be assessed by setting the tape measurement to the top of right iliac crest. The tape should be comfortable but not too tight around the skin and detained parallel with the floor. The measurement should be conducted in normal respiration. Aronne and Louis showed that women with a WC greater than 35 inches and men with WC greater than 40 inches are considered as a high- risk WC (Aronne and Louis, 2002). Therefore, by using waist measurement, health care practitioners could assess the general body fat distribution, which has a vital role in obesity adverse outcomes. Waist circumference (WC) classifies obesity into three general categories: central obesity, peripheral obesity and generalised obesity. Central obesity means having a waist to hip ratio (WHR) in the upper 95th percentile. Peripheral obesity means the individual holds a WHR in the lower 5th percentile, and generalised obesity is defined as individuals having a weight between the 5th and 95th percentile (Rees et al., 2008). Wendland et al. (2007) considered WHR a better indicator of obesity-related health risks than BMI in the non- pregnant general population.

Another method used to measure subcutaneous fat under the skin, including skin-fold thickness, biceps, triceps, subscapular, and suprailiac, is by grasping the fat using callipers. The disadvantage of this method is the unreliable measure of intra-abdominal adipose tissue (NOO, 2009).

Computed Tomography (CT) and magnetic resonance imaging scan (MRI), are two techniques which can be used in measuring fat distribution and MRI has the advantage of avoiding radiation exposure, which is an important consideration during pregnancy (Hu, 2008). Apart from above indices, others include the waist to height ratio, the abdominal sagittal diameter and the conicity index. Despite their accuracy, these indices are often more difficult to use because of scarcity of relevant valuable literature, in addition to being expensive (Scafoglieri et al, 2013)

In Kurdistan region, using weight indicator including BMI, waist circumferences and waist to hip ratio has not yet become common practice and most health care providers are not aware of these indicators. They use weight alone as an indicator of measuring weight gain or loss. In this project, the researcher utilised BMI measurements, whilst acknowledging the limitations of its use in assessing the level of risk of obesity. The other methods mentioned cannot be used due to the cost involved, associated risk and disadvantages towards pregnant women such as the waist and hip circumference measurements was not possible among pregnant women, due to the growing foetus within the abdomen.

At the end of this study, the researcher intends to introduce the use of BMI in maternity care settings and to contribute directly/indirectly to the provision of height and weight scale at various primary health care centres in the region of study and introduce a general course about measuring obesity through BMI indicator to health care providers. The aim is to create awareness in individuals and health care providers about classification and risks associated with being overweight and obesity. Within this research, BMI was used as a weight measurement indicator, which allows comparison with those reported in literature and ease in practice.