In 1997 the World Health Organisation (WHO) Expert Consultation on Obesity recognised the importance of abdominal fat mass (referred to as abdominal, central or visceral obesity), which can vary considerably within a narrow range of total body fat and body mass index (BMI). It also highlighted the need for other indicators to complement the measurement of BMI, to identify individuals at increased risk of obesity-related diseases. Two such proxy measures of abdominal obesity, which can complement the measure of BMI are waist size (circumference) and waist-to-hip ratio (WHR).
In my post ‘What is obesity – is it merely about BMI? What is obesity? I had highlighted that over the years, starting from the early 1980s, many research studies had confirmed the notion that rather than the excess body fat per se, regional distribution of body fat at different anatomic sites was much more important in driving the risk of cardiovascular diseases and other health hazards linked to obesity. In the same post I had described ‘abdominal obesity’ (individuals with excess intra-abdominal fat) and a characteristic obesity phenotype – ‘Asian Indian Phenotype or Paradox’ (Asians, particularly people in South-East Asia and China, displaying a greater amount of intra-abdominal fat for a given waist size [circumference] or BMI).
In my post “What is Obesity – is it merely about BMI? What is obesity? I had defined obesity as an abnormal accumulation of fat such that health is impaired. Body Mass Index is the most widely used measure of identifying obesity. However, in my post, I had cautioned that contrary to the general perception, obesity is not about BMI. In this post, I will be discussing what is Body Mass Index, its advantages and limitations. In addition to describing the method for calculation of BMI, for the ease of readers, I will be briefly discussing ‘BMI calculator tool’ and ‘BMI charts’.
What is Body Mass Index
Body Mass Index is a simple index of weight-for-height that is commonly used to assess ‘normalcy’ for body weight. It is defined as the body mass divided by the square of the body height. It is universally expressed in units of kg/m2, resulting from body mass in kilograms and height in meters. If pounds and inches are used as a measure of body mass and height respectively, a conversion factor of 703 is used. The formula for calculation of Body Mass Index is as under:
There is a widely prevalent myth amongst the populace that normal body weight always equals healthy weight and they do not need to worry about practising healthy lifestyle behaviours. However, nothing could be further from the truth. Normal weight obesity is well recognised entity. In my post “What is obesity – is it merely about BMI?” What is obesity? obesity had been defined as “excessive body fat accumulation (not weighing too much), which is associated with clear risks to health.” Surprisingly, even though obesity has been defined as the presence of ‘excess’ fat, there is no consensus on how to define obesity based on body fat content or body fat percentage.
WHO has established Body Mass Index (BMI) as the parameter for identifying overweight and obesity. Because of its simplicity, it has become a popular tool for assessing the prevalence of obesity and overweight at the population level. However, BMI has some serious limitations which will be discussed in detail in a subsequent post. The main limitation of BMI is that it cannot differentiate body fat from lean (fat-free) mass and central (intra-abdominal fat or visceral fat; colloquially known as belly fat) from peripheral fat. As a result, current BMI criteria miss more than half of the individuals with increased body fat percentage, who would otherwise be categorised as ‘obese’ using the WHO criteria of excess body fat, especially in older adults.
In my earlier post “Is obesity a disease or a risk factor for other conditions”? I had highlighted that now obesity is recognised universally as ‘a chronic, relapsing, progressive disease process.’ However, misconceptions still abound about ‘what is obesity’, not only in the public at large but even among the health professionals. Traditionally, when talking about what is obesity, we tend to erroneously confuse how we measure obesity with the definition of obesity. One such popular and well-known measure of obesity, which will be discussed subsequently, is Body Mass Index (BMI). BMIHowever, obesity is not about BMI; at its most basic, the term obesity describes the presence of ‘excess’ fat in the body.
Definition of obesity
In the year 1998, WHO defined obesity as under:
“A condition of abnormal or excessive body fat accumulation, to the extent that health may be impaired.”
In the year 2010, Scottish Intercollegiate Guidelines Network, part of the NHS Quality Improvement Scotland, described obesity as under:
“Obesity is defined as a disease process characterised by excessive body fat accumulation with multiple organ-specific consequences.”
As I begin writing about obesity on my blog, I want to start by addressing a fundamental question – Is obesity a disease? Or it is primarily a risk factor for other conditions rather than a disease in its own right? What is obesity? The issue has been historically debated. The need to address this question has been warranted by the emergence of obesity as a global epidemic and its implications for health. Chronic Diseases: the Silent Killers.
Magnitude of obesity
Before we address the question, is obesity a disease? let us consider the prevalence of obesity globally. As per WHO data, worldwide obesity has tripled since 1975. In 2016, more than 1.9 billion adults, 18 years and older, were overweight. Of these 650 million were obese. In terms of percentage, these figures translate to 39% and 13% respectively, of adults aged 18 years and over. As will be discussed in subsequent posts, obesity is responsible for the growing prevalence of various lifestyle diseases. As a result, obesity has come to be regarded as “the single greatest threat to public health for this century.” More worryingly, childhood obesity has been growing at a menacing pace. As per WHO, 41 million children under the age of 5 were overweight or obese in 2016. Over 340 million children and adolescents were overweight or obese in 2016. Almost half of all overweight children under 5 lived in Asia and one quarter lived in Africa.
Chronic diseases, also known as noncommunicable diseases or lifestyle diseases, are the leading killers and cause an unacceptable number of people to die prematurely and often after years of needless suffering and disability. Is obesity a disease? Unfortunately, this trend is increasing at a rapid pace. As per the WHO data, while in the year 2005, 60% of total deaths globally (35 million out of estimated 58 million deaths) were on account of these diseases, in the year 2012 this number jumped to 68% (38 million out of 56 million deaths) and in 2015 this figure increased to 70%. This is more than double the number of deaths from all infectious diseases (including HIV/AIDS, tuberculosis, and malaria), maternal and perinatal (relating to the time immediately before and after a birth) conditions, and nutritional deficiencies combined. More than 40% of these (16 million) were premature deaths under the age of 70 years. Lifestyle diseases: the biggest man-made disaster.
Impact of Chronic Diseases
These conditions not only cause premature deaths, and enormous suffering, severely impacting the quality of life, but also threaten the economy of a country and reduce developmental potential.
When one hears of the term ‘man-made’ disasters, the incidents that instantaneously come to mind are industrial accidents, nuclear disasters, stampedes, fires, and oil spills. No doubt these incidents have caused innumerable loss of lives and environmental damage, however, lifestyle diseases are the leading killers globally. As they are mostly caused by the ‘way we live’, they can be called the biggest man-made disaster. Before we proceed further, let us first understand as to what are lifestyle diseases.
What are lifestyle diseases?
Lifestyle diseases are a new breed of killer diseases that occur as a result of prolonged exposure to a set of similar risk factors. Unlike infectious diseases, they are mostly not caused by any microorganisms, and as such are not contagious. Hence, the World Health Organisation (WHO) has labelled them as noncommunicable diseases (NCD). As most NCDs are chronic – of long duration and slow progression, they are also known as chronic diseases. As the way people live plays an important role in the causation of these diseases, they are also referred to as Lifestyle diseases. Chronic diseases: the silent killers.
Wellness sells, and people are buying. But are they choosing ‘fleeting fancy’ over ‘lasting change’?
Wellness is today a buzzword in the health industry. Wellness sells, and people are buying. The wellness industry is growing at a frenetic pace. This can be gauged from the data released by the Global Wellness Institute. The global wellness market grew 10.6 per cent to $3.72 trillion from 2013 to 2015, even as the global economy shrank 3.6 per cent during the same period.
As I begin my new blog, it would be prudent to explain the terms ‘Wellness’ and ‘Holistic Health’; both today buzzwords in the health industry. Health, as we commonly understand as a layman, is the “absence of disease.” However, even though, people may lack the physical symptoms of a disease, they may still be bored, lack energy, and never feel like doing anything or simply unhappy with their lives. Such emotional states often set the stage for physical and mental disease. You will also notice that these feelings are aggravated or mitigated by what is happening around you; you are touched by everything that happens in your surroundings.
Even celebrities who seem to HAVE IT ALL, may not be happy. We come across people who are famous, rich, successful and inspiration for many – they seem to have it all, yet many of them have talked about feeling hollow from within, suffering from panic attacks, and even about being depressed. In an interview with The Telegraph a couple of years ago, Prince Harry had said: “I’ve spent most of my life saying ‘I’m fine. I can safely say that losing my mom at the age of 12 and shutting down all my emotions for the last 20 years has had quite a serious effect on my life…I have probably been very close to a complete breakdown on numerous occasions.” The most decorated Olympian of all time, swimmer Michael Phelps, while talking about his battle with loneliness within, said he was grateful for not taking his own life. So, obviously, there is something beyond the absence of disease which is necessary to help you feel better about yourself – energetic, joyous, at peace with your own self and your surroundings and have a purpose and meaning to life.
Definition of Health
The World Health Organisation has recognised that health is multi-dimensional and has therefore defined health thus:
“Health is a state of complete physical, mental, and social well-being and not merely an absence of disease or infirmity.”
In addition to the three specific dimensions envisaged in the WHO’s definition of health, other dimensions such as spiritual, emotional, and vocational have come to be recognised as ones which have a significant impact on health and well-being. Before we proceed further, it would be prudent to understand these dimensions and how they interact with each other.
Physical health is the most visible of the various dimensions of health. The state of physical health implies the notion of “perfect functioning” of the body.
In simpler terms, mental health encompasses your thoughts, knowledge, attitudes, and beliefs – your analytical self. Thoughts may seem to be something very innocuous and we all have them all the time. However, the power of thoughts is such that “the quality of your thinking determines the quality of your life” – they act as manures for your brain. Therefore, it is important to watch the quality of your thoughts.
It’s your feelings – your range of emotions from fear to anger to love and joy.
Social well-being is the extent to which you feel a sense of belonging and social inclusion; a connected person is a supported person. Social isolation and loneliness could be a greater threat to public health than obesity, researchers say. Being connected to others socially is widely considered a fundamental human need – crucial to both social well-being and survival. “There is robust evidence that social isolation and loneliness significantly increase the risk of premature mortality, and the magnitude of the risk exceeds that of many leading health indicators.” So Lonely I Could Die. Indeed many nations around the world now suggest we are facing a ‘loneliness epidemic’ amidst a sea of humanity. Establish a respectful cooperative relationship with your family, friends, community, and the environment.
It is the intangible “something” that transcends physiology and psychology. It primarily relates to one’s own journey to discover things of importance in life: your relationship with yourself and your relationship with a Higher Power. Its main purpose is to find purpose and meaning in life.
What Makes a ‘Whole’ person?
The above five key aspects make you a WHOLE PERSON. The concept is based on the law of nature that a ‘whole’ is made up of interdependent parts. The ecosystem (ecological system) of which we are a part, includes all of the living things (plants, animals, and organisms) in a given area and the non-living components (air, water, sun, soil etc.). Both the living and non-living components have a complex interaction and depend on each other; the absence of one member or one non-living factor can affect all parties of the ecosystem. Similarly, the various dimensions which constitute a ‘whole’ person constantly interact and affect each other; when one of these aspects is out of balance, it can impact all the other aspects. For example, if we are nervous or anxious, this may result in a physical reaction such as a headache; when we are angry and stressed over a long period of time, we could possibly develop gastric ulcer or migraine. This relationship between your different aspects is often referred to as a mind-body connection.
WELLNESS is a state in which ‘needs’ of each of the five key aspects are met and all aspects of your WHOLE SELF are able to work in harmony with each other.
The basic needs of each aspect of whole you, which need your attention and care to perform optimally as follows:
The Physical You (your body)
Regular optimal exercise – both aerobic and muscular fitness; healthy, balanced diet; healthy body weight; and adequate rest.
Mental You (your thoughts)
Inculcate positive thoughts and viewpoints, a positive self-image and self-supporting attitudes.
Emotional You (your feelings)
Ability to forgive and ‘let go’ is the mainstay of your emotional health. Equally important, let your feelings be heard. Share love and compassion; laugh and experience happiness; establish joyful relationships, including with your own-self.
Social You (your interpersonal relationships)
Connect with family, friends, neighbours, and colleagues at the workplace.
Spiritual You (your spirit)
Take time to reflect, meditate and pray for inner calmness, and trust in your inner knowing.
Holistic Health Spectrum
Health and disease lie along a continuum, where premature death is the lowest point on the spectrum and as you move rightwards, the highest point corresponds to optimum wellness described above.
Fig. Health Spectrum
The centre or the neutral point represents a point where there is no ‘apparent’ illness. Thus, it is obvious from the above health spectrum that health is not a static state, rather it’s a dynamic process that fluctuates within a range of optimum well-being to various levels of illness, including premature death. There are degrees or ‘levels of wellness’ as there are degrees of severity of illness. Being in a state of optimum wellness does not preclude periods of illness, nor does it attempt to deny that death is a natural part of life. Therefore, what this implies is that health is a state not to be attained once and for all, but instead, it requires constant care – you don’t just get well and stay well.
The sick-care model
The conventional medicine (the ‘sick-care’ model) typically treats illness, injuries, and symptoms to bring the individual to a ‘neutral point’, where there is no longer any apparent illness. However, the wellness paradigm directs you beyond the neutral point, further along the health spectrum, towards optimum wellness. The right half of the Health Spectrum, thus, shows that even if a person is not suffering from any apparent disease, there is still a lot to be gained by attempting to reach the state of maximum well-being, where a person is not only free from any illness but everything will function at the very best that is possible.
Holistic Health meaning
The term ‘Holistic’ was coined in 1926 by a South African soldier and statesman Gen JC Smuts, as a philosophical term. Viewing the universe in terms of ‘wholes’ – that is, organisms and systems instead of molecules and atoms – he derived holism from the Greek word holos, meaning ‘whole’. Holistic Health is a concept that goes beyond curing of illness to one of achieving optimum wellness. It goes beyond just eliminating symptoms and strives to achieve maximum well-being, where everything is functioning at the highest level possible. This broader (w)holistic approach to health, promotes wellness by integrating and balancing the various aspects which constitute the ‘whole person’. It’s an ongoing process and a way of life.
History of Holistic Health
Though this concept of Holistic Health has been integrated into modern medicine only in the recent past, ancient healing traditions, as far back as 5000 years ago, in India and China, stressed living a healthy way of life in harmony with nature. Socrates (4th century BC), a Greek philosopher, warned against treating only one part of the body “for the part can never be well unless the whole is well.” The significance of treating the body as a whole’ and need for balance between the various aspects of a person to maintain health, can be traced back to Ayurveda, a medical system of Indian origin, which originated about 5000 BC. In Ayurveda, there is a ‘tridosha theory of disease’. The doshas or humors are: vata (wind), pitta (gall), and kapha (mucous). The disease was explained as a disturbance in the equilibrium of the three humors; when these were in perfect balance and harmony, a person is said to be healthy.
The significance of preventive treatment
The health spectrum has been viewed as promoting preventive treatment, which improves well-being before an individual presents with signs or symptoms of illness. This concept of ‘preventive’ medicine is also not new. In the Chinese system of medicine, considered one of the world’s oldest systems of medicine, “the great doctor is one who treats not someone who is already ill but someone not yet ill”. Galen (130-205 AD), the physician to the Roman emperor, Marcus Aurelius, and a great teacher and author, stated about health: “Since both in importance and in time, health precedes disease, so we ought to consider first how health may be preserved, and then how one may best cure diseases.”
In conclusion, by adopting the principles of holistic health you can enjoy better health, have increased energy, greater enthusiasm, an enhanced sense of well-being and a greater sense of joy; it can help find purpose and meaning to life and promotes inner calmness. This can be achieved by exercising your ‘power of choice’: choose wellness-oriented lifestyles, positive thoughts, and attitudes, love and compassion, time to be quiet and reflect, forgive and let go.