Review ArticleFor Researchers on Obesity Historical Review ofExtra Body Weight Definitions

Marina Komaroff

Department of Epidemiology and Biostatistics SUNY Downstate Medical Center Brooklyn NY 11203 USA

Correspondence should be addressed to Marina Komaroff genmar2kgmailcom

Received 26 January 2016 Revised 20 April 2016 Accepted 28 April 2016

Academic Editor Francesco Saverio Papadia

Copyright copy 2016 Marina Komaroff This is an open access article distributed under the Creative Commons Attribution Licensewhich permits unrestricted use distribution and reproduction in any medium provided the original work is properly cited

Rationale The concept of obesity has been known since ancient world however the current standard definition of obesity wasendorsed only about a decade ago There is a need for researches to understand multiple approaches to defining obesity and howand why the standard definition was developed The review will help to grasp the complexity of the problem and can lead tonovel hypotheses in obesity research Objective This paper focuses on the objective to understand historical background on thedevelopment of ldquoreference and standard tablesrdquo of weight as a platform for normal versus abnormal bodyweight definitionMethodsA systematic literature reviewwas performed to chronologically summarize the definition of body weight from time of Hippocratestill the year of 2010ConclusionThis paper presents the historical background on the development of ldquoreference and standard tablesrdquoof weight as a platform for normal versus abnormal body weight definition Knowledge of historical approaches to the concept ofobesity can motivate researchers to find new hypotheses and utilize the appropriate obesity assessments to address their objectives

ldquoThe secret of getting ahead is getting startedrdquoMark Twain

1 Introduction

In 2001 ldquoThe Surgeon Generalrsquos Call to Action to Preventand Decrease Overweight and Obesityrdquo set up the firstobjective as ldquoto promote the recognition of overweight andobesity as major public health problemrdquo in the United States[1] The Surgeon Generalrsquos Call to Action recognized thatoverweight and obesity have reached nationwide epidemicand underscored that the urgent goals are to prevent and treatthe obesity and chronic diseases associated with obesity [1 2]

In 2001 Food and Drug Administration and NationalInstitutes of Health developed the Healthy People 2010 pro-gram that was committed to prevention and treatment ofoverweight and obesity to reduce chronic diseases associatedwith diet and weight [3] In 2010 report Healthy People2010 summarized that the age-adjusted proportion of healthy(bodymass index (BMI)lt 250 kgm2) adults (agege 20 years)decreased from 42 in 1988ndash94 to 31 in 2005ndash08 andthe proportion of obese (BMI ge 300 kgm2) increased from

23 to 34 for the same period of time [3] The expertsconcluded that the ten-year goal to prevent and treat theobesity was not met [3] Instead the nation was movingaway from the objective to promote health and reducechronic diseases associated with diet and weight [3] Thisunderscores the extent of the problem and urgency to seeka solution

Clear understanding of the concept of obesity and itsmeasurements should be the first step for successful researchin obesity arena The topic of obesity is extremely complexEven though enormous research has been done to discoverthe causes of obesity there is still no clear statement if obesityis exposure or outcome For example there is still a questionif psychological depression causes obesity or obesity is a causefor psychological depression This paper does not declareany perception on obesity and does not aim to cover causesandor consequences of obesity It aims to unfold all pointsof view on the obesity concept and definition through thechronological review of its development

Hindawi Publishing CorporationJournal of ObesityVolume 2016 Article ID 2460285 9 pageshttpdxdoiorg10115520162460285

2 Journal of Obesity

2 What Is Obesity

Hippocrates (460 BCndash370 BC) described the health forhuman body as a balance of four humors (fluids) blood blackbile yellow bile and phlegm and any deficiencies or extraswere considered causes of diseases [4] Obesity was definedas the surplus of humors [4] For a big part of human historyextra weight was considered as an indication of good healthaswell aswealth and prosperityHippocrateswas the first whorealized that obesity leads to infertility and earlymortality [5]It took more than two thousand years to test his hypothesesscientifically and evaluate how ldquosurplus of humorsrdquo relates todifferent health outcomes and early deaths

The weight measurement and evaluation criteria arenecessary to define overweight and obesity In 1885 intro-duction of a penny scale first in Germany then in the UnitedStates allowed measuring the body weight to the nearestpound [6] Since then a new era for weight assessments andsearch for ldquohealthyrdquo weight started In the beginning of 20thcentury a low body weight was a concern because of threatof pneumonia and tuberculosis especially for young andunderweight adults [7] Healthy weight became the criteriafor the individualrsquos enrollment into the insurance policies [7ndash12] The question of ldquoidealrdquo weight and the acceptable level ofdeviation from ldquoidealrdquo became the most important questionsfor insurance companies [7ndash12] Overweight was defined asweight that exceeded the threshold from the reference valuewhere reference value was derived from the distribution ofpopulation Based on observed association of body weightwith mortality the Metropolitan Life Insurance Company(MLIC) was able to develop the standard tables for ldquoidealrdquo(MLIC 1942) [9 10] and then ldquodesirablerdquo weight (MLIC 1959)[11 12] and finally just ldquoheight to weightrdquo tables (MLIC1983) [13 14] Those standard tables became the platform fordevelopment of current definition for underweight normaloverweight and obese individuals based on the body massindex (BMI) cut-offs [15 16]

3 Measurements of Obesity

One of the ways to assess overweight and obesity is tocompare the individualrsquos weight versus the reference valuedefined as the average population weight and another wayis to compare it with the weight standards that derivedfrom the relationship between body weight and mortalityor morbidity outcomes The background of developmentreference or ldquoaveragerdquo tables is outlined in Section 31 Theprocess of how tables of ldquoaveragerdquo weight were transformedinto the ldquoidealrdquo weight standards tables based on the lowestrate of mortality is described in Section 32 The historicalbackground of development of both is summarized inTable 3

31 ldquoNormal Manrdquo and the ldquoAveragerdquo Weight Tables Belgianastronomer and mathematician Adolphe Quetelet (1796ndash1874) was fascinated by the probability theory and passion-ately applied probability calculus into the physical charac-teristics of human body [19] His idea was to demonstratethat normal Gaussian distribution can be applied to physicalattributes of humans and he was looking for the ldquonormrdquo [19]

Table 1 Table of height and weight [17 page 139]

Height Weight (pounds)Feet Inches5 1 1205 2 1255 3 1305 4 1355 5 1405 6 1435 7 1455 8 1485 9 1555 10 1605 11 1656 infin 170

In 1831-32 Quetelet conducted what has been considered thefirst cross-sectional study of newborns and children based ontheir growth in height and weight [19] Adolphe Queteletrsquoscross-sectional studies of human development revealed thatweight grows as a cube of babyrsquos height during the firstyear of life and then as a square of height until pubertyand almost stops after the age of twenty-five [19] In 1835Quetelet published a book entitled ldquoA Treatise on Man andthe Development of His Aptitudesrdquo with the conclusion thatindividualrsquos weight increases as a function of the square oftheir height and introduced the anthropometric index asweight in kilograms divided by the square of the height inmeters which is now known as Quetelet Index [19 years 1835and 1842 English translation] Adolphe Quetelet was the firstwho developed the table of the ldquoaverage weightrdquo at ages 2030 40 50 and 60 for a sample of Belgian men and women[7 19]

In 1846 Hutchinson a British surgeon published a tableof the ldquoaveragerdquo weights of 30-year-old men for each inch ofheight from5 feet 1 inch to 6 feet at age of 30 based on statisticsof 2650 Englishmen [7 20] This table became the referencefor English population and was used by the life insurancecompanies as a guide to evaluate applicants [7 17]

In 1867 Fish published ldquoThe Agentrsquos Manual of LifeAssurancerdquo by the Mutual Life Insurance Company of NewYork [17] Table of height and weight (Table 1 [17 page139]) adopted English reference for American people basedon reviews from Minturn Post and Isaac L Kip who weremedical examiners for the Mutual Life Insurance CompanyofNewYork [17]The reference table for American populationldquodiffers slightlyrdquo from the English ones set by Hutchinson andoffered ldquowhat the best authorities regard as themost desirableproportion of the height of individuals to their weightrdquo [17]

In 1889 the Actuarial Society of America and the Asso-ciation of Life Insurance Medical Directors of America werefounded which made possible a uniformed approach to theindustry-wide height and weight tables [7] In 1912 Medico-Actuarial Mortality Investigation published the statistics ofheight and weight of insured people and set up a goal ldquotoprovide an accurate Standard Table of Heights and Weightsand to determine the influence of build on longevityrdquo [7]

Journal of Obesity 3

The whole process of development of standard weight tableswith major milestones is summarized in Section 32 andTable 3

32 Standard Tables of ldquoIdealrdquo Weight First tables of ldquoidealrdquoweights were developed by Dublin and Lotha (1882ndash1969) astatistician and vice president of the Metropolitan Life Insur-anceCompany (MLIC) [8]Thedata from approximately fourmillion MLIC policyholders from 1911 to 1935 were utilized[8] The main criterion for ldquoidealrdquo weight was longevity [8]Dublin and Lotha grouped policyholders into categories bysex height and weights but they could not fit the numbersinto normal curve until they divided the studied populationfurther into the three types of body frames small mediumand large [8] From the prospective of insurance the ldquobadweightrdquo was considered to be 20ndash25 with morbid obesityat 70ndash100 above the ldquoidealrdquo weight for a given frame [8]The ldquo1942-43 Metropolitan Height and Weight Tablesrdquo werecreated based on Dublin and Lotha work and became thenational standards for ldquoidealrdquo body weight [9 10] Thosetables were close representation of the longevity of Americanpopulation but contained little information about trend andcauses of mortality [9 10]

In 1959 ldquoThe Build and Blood Pressure Studyrdquo was con-ducted by the Society of Actuaries with collaboration of 26insurance companies to determine the mortality of insuredpersons according to variations in body build and bloodpressure [12 14] The weights were derived from data ofpeople with lowest mortality who were insured between 1935and 1953 and followed to 1954 in the United States andCanada [12] Measured heights and weights were of peoplewearing ldquoindoor clothing and shoesrdquo and included 20 ofself-reported values [12] ldquoFrame sizerdquo for this study was notbased on measurement of skeletal dimensions but arbitrarilydivided the distribution of relative weights on the assumptionthat skeletal size was associated with a personrsquos position inthat distribution [12] The association between body weightand mortality particularly from cardiovascular diseases wasdemonstrated and MLIC 1959 weight tables were createdwhere ldquoideal weightrdquo was replaced by the ldquodesirable weightrdquo[11]

In 1973 the Fogarty International Center Conference onObesity recommended guidance for body weight based onthe updates from the MLIC 1959 ldquodesirablerdquo weight tables[21] The updates meant creation of ldquoacceptable rangerdquo ofweight for a particular height by the rule that for men andwomen for each inch of height set up the range of weightwhere the weight in the lower limit of the small frame and theweight in the upper limit of the large frame form the range ofweights for the standards [21 31] The ldquoacceptable rangerdquo forweight was converted into the suggested body mass index as201ndash250 for men and 187ndash238 for women [21] These tableswere adopted in the report of obesity by Royal College ofPhysicians in 1983 [31]

In 1979 the second study of ldquoThe Build and BloodPressure Studyrdquo produced the revised tables based on themortality of insured people from 1950 to 1972 where ldquodesir-ablerdquo weights were higher than those in previous study [14]Based on the data from new study the MLIC 1959 tables

Table 2 Range of acceptable body weight [18]

Height (feet-inches) Men (pounds) Women (pounds)410158401010158401015840 92ndash119410158401110158401015840 96ndash12951015840010158401015840 96ndash12551015840110158401015840 99ndash12851015840210158401015840 112ndash141 102ndash13151015840310158401015840 115ndash144 105ndash13451015840410158401015840 118ndash148 108ndash13851015840510158401015840 121ndash152 111ndash14251015840610158401015840 124ndash156 114ndash14651015840710158401015840 128ndash161 118ndash15051015840810158401015840 132ndash166 122ndash15451015840910158401015840 136ndash170 126ndash150510158401010158401015840 140ndash174 130ndash163510158401110158401015840 144ndash179 134ndash16861015840010158401015840 148ndash184 138ndash17361015840110158401015840 152ndash18961015840210158401015840 156ndash19461015840310158401015840 160ndash19961015840410158401015840 164ndash204Note height without shoes and weight without clothes

for ldquodesirablerdquo weight were replaced by MLIC 1983 tables ofldquoheight and weightrdquo [13]

Overweight and obesity are the nutrition-related disor-ders which are caused by the accumulation of extra fat aswas stated by the Department of Health and Human Services(HHS) and the Department of Agriculture (USDA) whichwere responsible for issuing the ldquoDietary Guidelines for Amer-icansrdquo in 1980 and for updating the document every 5 years[32] The goal of the document was to provide nutritionaland dietary information and guidance for general public In1980 US Department of Agriculture and US Department ofHealth Education and Welfare published the first edition ofnutritional ldquoDietary Guidelines for Americansrdquo and advisedthe public based on current knowledge of the relationshipof diet to health and disease [18] The guidance includeda table with suggested body weight based on the tablesrecommended by Fogarty International Center Conferenceon Obesity with the adjustments for height and weight [18]Adjustment for height was done as 1 or 2 inches (254 and508 cm) for shoes and 10 lbndash6 lb for clothes (Table 2) [18 3334]

The National Institutes of Health Consensus Develop-ment Conference on the Health Implications of Obesityapplied criteria for defining overweight severe overweightobesity and severe obesity to the National Health andNutrition Examination Survey 1976ndash80 (NHANES II) data[22] ldquoOverweightrdquo was defined by a BMI (body massindex = weight in kilograms divided by weight in meterssquared) ge85th percentile with ldquosevere overweightrdquo ge95thpercentile of 20-year-old to 29-year-old men and women[22] ldquoObesityrdquo and ldquosevere obesityrdquo were defined using thesame criteria only the sum of the triceps and subscapularskinfold thicknesses instead of the body mass index [22]The

4 Journal of Obesity

Table3Develop

mento

fweightstand

ardtables

Year[ref]

Author

Criterialowast

Popu

latio

nScreening

Develo

pment

Milesto

neoutcome

1842

[19]

Quetelet

Tablesw

eighttoheight

byage

grou

p203040

50and60

Belgianmen

andwom

enWith

clothes

and

shoes(as

is)

Develo

pedatableo

fthe

averagew

eight

byagesfora

sampleo

fBelg

ianmen

andwo

men

ldquoAverage

weightrdquo

Belgian

1846

[20]

Hutchinson

Tablesw

eighttoheight

for3

0yo

En

glish

men

from

51015840110158401015840

to6feet

5feet1inchto

6feet30y

o

2650En

glish

men

Averagew

eightsof

30yo

men

for

each

inch

ofheight

from

51015840110158401015840

to6feet

ldquoAverage

weightrdquo

English

1867

[17]

Fish

Tablesw

eighttoheight

for3

0yo

American

men

from

51015840110158401015840

to6feet

American

MedicalRe

view

ofEn

glish

Tables

(from

John

Hutchinson)

TheA

gentrsquosManua

lofL

ifeAssurance

ldquoAverage

weightrdquo

American

1912

[7]

TheA

ssociatio

nof

LifeInsurance

MedicalDire

ctors

andtheA

ctuaria

lSo

cietyof

America

Tablesbased

onrateofmortality

weightb

yheight

tables

form

enandwom

enby

age

Mortalityforinsured

popu

latio

n

Season

alconsiderationto

have

thes

ame

clothes

andshoes

ReportofTh

eJoint

Committee

onTh

eMedico

-Actua

rial

MortalityInvestigationldquoA

verage

weightm

ayno

thavethe

lowest

mortalityrdquomdashwhatisidealweight

ldquoIdealweightrdquobasedon

longevity

1937

[8]

Dub

linandLo

tha

(1882ndash1969)

Metropo

litan

Life

InsuranceC

ompany

fram

e[8]1937

Tablesw

eighttoheight

bysexand

body

frame

sim4millionpeop

leinsured

byMetLife1911ndash

1935

Heightwith

street

shoesW

eighton

lyindo

orclo

thes

Dub

lindividedthea

verage

weights

into

threetypes

ofbo

dyfram

essmall

mediumand

largeF

rom

the

prospectiveo

finsurancethe

bad

weightw

asconsidered

tobe

20ndash25

with

morbidob

esity

at70ndash100above

theldquo

idealrdquo

ldquoIdealweightrdquo

(based

onlowest

mortalityforinsured

popu

latio

n)

1942-3

[910]

Metropo

litan

Life

InsuranceC

ompany

(MLIC)

Tablesw

eightb

yheight

bysexand

body

fram

eLo

ngevity

criteria

weight

maintainedatthes

amelevelas

25yo

with

sameh

eightand

body

fram

e

Prop

osed

tables

forldquoideal

weightrdquoform

enand

wom

engt25

yobyfram

esiz

e

Heightwith

street

shoes

Weighton

lyindo

orclo

thes

Natio

nalStand

ards

forW

eight

bysexandbody

frameM

LIC1942-43

Obesity20aboveidealweight

ldquoIdealweightrdquo

1959

[1112]

TheB

uild

andBloo

dPressure

Stud

yTablesw

eightb

yheight

bysexand

body

fram

e

USandCa

nada-in

sured

(from

26lifeinsurance

companies)p

eople

1935ndash195420

self-repo

rted

Streetshoesa

ndindo

orclo

thes

RevisedMLIC1959

tables

Stan

dard

Tablesbasedon

associa

tion

with

mortality(

notm

orbidity)

distrib

utionof

weighttoheight

associationwith

minim

ummortality

(lowestd

eath

rate)O

besity20above

idealw

eight

ldquoDesira

blew

eightrdquo

1975

[21]

FogartyCenter

Con

ferenceo

nObesity

Rangeo

facceptablew

eight

SuggestedrangeB

MI

201ndash

250form

en187ndash

238forw

omen

Basedon

MLIC1959

Adjuste

dstr

eet

shoesa

ndindo

orclo

thes

Guidan

ceforb

odyw

eight

Rangeo

facceptable

weight

Journal of Obesity 5

Table3Con

tinued

Year[ref]

Author

Criterialowast

Popu

latio

nScreening

Develo

pment

Milesto

neoutcome

1979

[1314]

TheB

uild

andBloo

dPressure

Stud

ysecond

study

Tablesw

eightb

yheight

bysexand

body

fram

e

Insuredpeop

le1950ndash1972

10self-repo

rted

Streetshoesa

ndindo

orclo

thes

RevisedMLIC1983

tables

ldquoHeig

httowe

ight

tablesrdquo

1980

[18]

USDepartm

ento

fAgriculture

andUS

Departm

ento

fHealth

Edu

catio

nandWelfare

Adjuste

drangeo

facceptable

weighto

fage

andheight

specific

MLIC59

Adjuste

dstr

eet

shoesa

ndindo

orclo

thes

DietaryG

uidancefor

America

ns(1s

tedition)

Rangeo

facceptable

weight

from

ldquodesira

blerdquo

weighttables

1985

[2223]NationalInstituteo

fHealth

ldquoOverw

eightrdquoB

MIge

85th

percentileldquosevereo

verw

eightrdquo

BMIge

95th

percentileo

f20-year-oldto

29-year-oldmen

andwom

enldquoObesityrdquo

andldquosevere

obesity

rdquosam

efor

thes

umof

the

tricepsa

ndsubscapu

larskinfold

thickn

esses

NHANES

II1976ndash80

Men

andwom

en20ndash29yearso

ld

Criteria

matched

forrange

ofacceptableweight

notge

20of

desir

ableweight

form

idpo

into

fmedium-build

person

MLIC

83

Guidan

ceforb

odyw

eight

Overw

eight-o

besityBM

Ige278form

enge273forw

omen

SuggestedrangeB

MIfor

malesand

females

264ndash285(M

LIC59)2

72ndash269(MLIC

83)

Rangeo

facceptable

weight

1985

[24]

USDepartm

ento

fAgriculture

andUS

Departm

ento

fHealth

Edu

catio

nandWelfare

Overw

eighttranslatedto

BMIfor

mensim25-26andforw

omen

sim24-25

MLIC59

DietaryG

uidancefor

America

ns(2nd

edition)

Desira

blew

eight

1990

[25]

USDepartm

ento

fAgriculture

andUS

Departm

ento

fHealth

Edu

catio

nandWelfare

BMIge

25fora

ges19ndash

34andge27

fora

gesge

35years

Alladults(both

sexesc

ombined)

by2ageg

roup

s

DietaryG

uidancefor

America

ns(3rd

edition)translated

inBM

Ige25

for

ages

19ndash34andge27

fora

gesge

35years

Unhealthyw

eight

1995

[15]

2000

[26]

World

Health

Organization(W

HO)

Mortalitycurve

Internationald

ata

Mortalitycurves

forB

MIsele

ction

Internationa

lClassificationofWeig

htInternationa

lClassifi

catio

nofWeig

htbasedon

BMIlevel

1995

[27]

USDepartm

ento

fAgriculture

andUS

Departm

ento

fHealth

Edu

catio

nandWelfare

BMIge

25fora

llages

Alladults(bothsexes

combined)

fora

llages

Noshoesno

clothes

DietaryG

uidancefor

America

ns(4th

edition)

Health

yweig

ht

1998

[2]

NationalInstituteo

fHealth

(NIH

)and

NationalH

eartLun

gandBloo

dInstitute

(NHLB

I)

Relatio

nof

BMIand

riskof

morbidityandmortality

RCTandepidem

iological

studies

Clinica

lGuidelin

eson

the

Identifi

catio

nEvaluatio

nan

dTreatm

entofO

verw

eight

andObesity

inAd

ults

Assessm

enta

ndtre

atmentm

anagem

ent

ofoverwe

ighta

ndobesity

6 Journal of Obesity

Table3Con

tinued

Year[ref]

Author

Criterialowast

Popu

latio

nScreening

Develo

pment

Milesto

neoutcome

2010

[16]

USDepartm

ento

fAgriculture

andUS

Departm

ento

fHealth

Edu

catio

nandWelfare

WHOInternationalC

lassificatio

nof

Weightb

ased

onBM

Ilevelwas

adop

tedforU

Spo

pulatio

nUSA

Matches

with

WHOandNIH

andNHLB

Icriteria

DietaryG

uidancefor

America

ns(7th

edition)lowastlowast

BMIclassification

matcheswith

WHOand

NIH

andNHLB

I1998

lowastCr

iteria

fortablegeneratio

nlowastlowastNexteditio

nisexpected

in2015

ldquoNationalN

utritionMon

itorin

gandRe

lated

Research

Acto

f1990rdquomdashPu

blicLaw101ndash445Title

IIISectio

n301sta

tedthatarepo

rtentitledldquoD

ietaryGu

idelinesfor

America

nsrdquos

hallcontainnu

trition

alanddietary

inform

ationandguidelines

forthe

generalpub

licandldquoshallbe

prom

oted

byeach

Federalagencyin

carrying

outany

Federalfoo

dnu

trition

orh

ealth

programrdquo[28]

Journal of Obesity 7

numbers came to the criteria of defining ldquooverweightrdquo as BMIge278 kgm2 for men and BMI ge273 for women [22] Thesecriteria matched with 20 or more above the ldquodesirablerdquoweight in the MLIC 1983 tables (from midpoint of the rangefor a medium-build person) [22] These definitions becamewidely accepted as the standards [22] Nevertheless numbersfor ranges of acceptable ldquonormalrdquo BMI were different fromthose based on the version of standard tables for example forMLIC 1959 264 (men) and 285 (women) and forMLIC 1983272 (men) and 269 (women) [23] Moreover the recom-mended requirement differed from the guidelines set up byFogarty Center and the Royal College of Physicians [21 35]Such discrepancies in the guidance pointed out the technicalproblems of weight to height tables the discrepancies ofmeasurements (shoes clothes and approximately 20 self-reported data in MLIC 1959 and 10 in MLIC 1983) andpopulation selection [35] It brought up an urgent need tostandardize definition of overweight and obesity and thesearch for weight to height index of body weight started

In 1985 the Department of Health and Human Services(HHS) and the Department of Agriculture (USDA) issuedthe second edition of ldquoDietary Guidelines for Americansrdquo [24]That document used the ldquodesirablerdquo weight to height tablesfromMLIC 1959 and translated the numbers into overweightlevel of BMI for men sim25-26 and for women sim24-25 [24 34]In the 1990 third edition tables for men and women werecombined into one and presented by two age groups whereldquounhealthyrdquo weight was translated into BMI ge 25 for ages 19ndash34 and ge27 for ages ge35 years [25 34]

In 1990 the ldquoNational Nutrition Monitoring and RelatedResearch Act of 1990rdquo Public Law 101ndash445 Title IIISection 301 stated that a report entitled ldquoDietary Guidelinesfor Americansrdquo shall contain nutritional and dietary informa-tion and guidelines for the general public and be publishedat least every five years [28] Each such report ldquoshall bepromoted by each Federal agency in carrying out any Federalfood nutrition or health programrdquo [28] Basically the lawstated that the definition of healthy weight or overweightfrom the Dietary Guidelines for Americans should be usedby the constituent Federal agencies [28]

In Geneva in 1995 WHO Expert Committee on PhysicalStatus published technical reportThe Use and Interpretationof Anthropometry [15] It was acknowledged that the basicanthropometry measurements of human body are weightand height [15] It was recommended to combine twobasic measurements weight and height into the body massindex (weightheight2) or ponderal index (weightheight3)for adults and three anthropometric indexes with consider-ation of age were described for children weight for heightheight for age and weight for age [15] The WHO ExpertCommittee on Physical Status proposed to classify differentlevels of BMI with cut-off points of 25 30 and 40 based onldquoarbitrarymethod of association betweenBMI andmortalityrdquo[15] WHO Expert Committee on Physical Status refer-enced the meta-analysis performed by Troiano et al whichincluded 17 studies with 37 substudies with 350000 menand gt38000 deaths plus six studies with 12 substudies with250000 women and 13700 deaths and presented the U-shapemortality rates that sharply increased when BMI lt185 and

Table 4 International classification of adults based on body massindex

Classification BMI (kgm2)Cut-off points Additional cut-off points

Underweight lt1850 lt185Severe thinness lt1600 lt160Moderate thinness 1600ndash1699 1600ndash1699Mild thinness 1700ndash1849 1700ndash1849

Normal 1850ndash2499 1850ndash22992300ndash2499

Overweight ge2500 ge2500

Preobese 2500ndash2999 2500ndash27492750ndash2999

Obese ge3000 ge3000

Class I 3000ndash3499 3000ndash32493250ndash3499

Class II 3500ndash3999 3500ndash37493750ndash3999

Class III ge4000 ge4000Source fromWHO 1995 WHO 2000 and WHO 2004 [15 26 29 30]

gt300 kgm2 with the acceptable BMI range as 185ndash2500 [15page 322] The WHO experts underscored that the cut-offswere chosen arbitrarily based on the ldquovisual inspection ofthe relationship between BMI and mortalityrdquo [15] curve forexample ldquothe cut-off of 30 is based on the point of flexionof the curverdquo [15] The authors suggested that this methodshould be revised in the future in terms of BMI associationwith health risk [15]

In 1995 the next step was taken to combine not justboth sexes but also age groups where ldquohealthyrdquo weight wastranslated in BMI ge25 for all adults in the fourth editionof ldquoDietary Guidelines for Americansrdquo [27] The report usedWHO criteria for publishing healthy weight ranges for menand women by each inch of height [27] The edition was veryimportant because it led to publishing the prevalence andtrends on overweight (BMI ge 25) preobese (BMI 250ndash299)class 1 (BMI 300ndash349) class 2 (BMI 350ndash399) and class3 (BMI ge 400) obese in the United States data from 1960to 1994 (NHANES I II and III) for first time to facilitatecomparison with international data [2]

Clinical Guidelines on the Identification Evaluation andTreatment of Overweight and Obesity in Adults (NIH Septem-ber 1998) defined overweight as a body mass index (BMI) of25 to 299 kgm2 and obesity as a BMI of ge30 kgm2 [2] Thepanel of experts came to this classification based on evidencefrom approximately 394 randomized controlled trials (RCTs)and multiple observational studies about BMI and risk ofmorbidity and mortality [2] The classification matched withone suggested by WHO [2 15]

In 2000 World Health Organization (WHO) definedoverweight and obesity as ldquothe disease in which excess bodyfat has accumulated to such an extent that health may beadversely affectedrdquo [26] and underscored that the practicaldefinition of obesity is based on the level of body massindex (BMI) [15 26]Themost recent version of international

8 Journal of Obesity

Table 5 Overweight and obese children and adolescents [16]

Category Children and adolescents (BMI for agepercentile rangelowast) Adults (BMI)

Underweight Less than the 5th percentile Less than 185 kgm2

Healthy weight 5th percentile to less than the 85th percentile 185 to 249 kgm2

Overweight 85th percentile to less than the 95th percentile 250 to 299 kgm2

Obese Equal to or greater than the 95th percentile 300 kgm2 or greaterlowastGrowth charts are available at httpwwwcdcgovgrowthcharts

classification for adults developed by WHO is presented inTable 4 [15 26]

BMI has never been a perfect index for children becauseit correlates with height In the United States Centers forDisease Control and Prevention (CDC) 2000 used fivenationally representative surveys to develop BMI charts forchildren in the United States the National Health Examina-tion Surveys (NHES) II and III in the 1960s the NationalHealth and Nutrition Examination Surveys (NHANES) I andII in the 1970s and NHANES III for the period of 1988ndash1994 Those charts included gender-specific BMI by singlemonth of age curves of growth Currently they are used inthe United States for children who are 2ndash19 years old todefine ldquooverweightrdquo as BMI ge95th percentile or ldquoat risk foroverweightrdquo if BMI is between 85th and 95th percentiles[26 36]

International surveys of six large and nationally repre-sentative cross-sectional growth studies from Brazil GreatBritain Hong Kong Netherlands Singapore and the UnitedStates were used by International Obesity Task Force (IOTF)to establish the cut-off points for overweight and obeseamong children and adolescents [37] In summary partic-ipants of IOTF agreed to link childhood overweight andobesity to the cut-offs for adults Based on each of the surveyspercentile curves were drawn in such a way that they passedthrough BMI cut-off points of 25 and 30 kgm2 at age of18 years and the resulting curves were averaged by age andgender to provide cut-off points for 2 through 18 years of age[37] This way less arbitrary and more internationally basedcut-offs were proposed [37]

In the current edition ofDietaryGuidelines for Americans2010 the BMI cut-offs are consistent with internationallyrecommended [16] By the Public Law 101ndash445 Title IIISection 301 all Federal agencies have made the transitionto define overweight and obesity as a BMI consistent withrecommendations in the current edition ofDietaryGuidelinesfor Americans [16 28] The table of weight category basedon BMI level from Dietary Guidelines for Americans 2010 ispresented in Table 5 [16]

4 Summary

There is nationwide and global epidemic of obesity As thefirst step to conquer a problem the concept of obesity shouldbe clearly understood through the historical process that ledto the worldwide accepted standard definition This paperpresents the history of developing current standard definitionof overweight and obesity Understanding the roots will lead

to the successful research on obesity with a goal to defeatnational and global epidemic

Competing Interests

The author declares that there are no competing interests

Acknowledgments

The author thanks Drs Michael Szarek Michael Walsh andElizabeth Helzner for assistance with development of thisproposal

References

[1] US Department of Health and Human Services The SurgeonGeneralrsquos Call to Action to Prevent and Decrease Overweight andObesity US Department ofHealth andHuman Services PublicHealth Service Office of the Surgeon General Rockville MdUSA 2001

[2] National Institutes of Health ldquoClinical guidelines on the identi-fication evaluation and treatment of overweight and obesity inadults-the evidence reportrdquoObesity Research vol 6 supplement2 pp 51Sndash209S 1998

[3] ldquoNutrition and overweightrdquo in Healthy People 2010 chapter 19pp 1ndash15 Food and Drug Administration National Institutes ofHealth Hyattsville Md USA 2001 httpwwwcdcgovnchsdatahpdata2010hp2010 final review focus area 19pdf

[4] H Christopoulou-Aletra andN Papavramidou ldquoMethods usedby the Hippocratic physicians for weight reductionrdquo WorldJournal of Surgery vol 28 no 5 pp 513ndash517 2004

[5] D Haslam ldquoObesity a medical historyrdquoObesity Reviews vol 8supplement 1 pp 31ndash36 2007

[6] H Schwartz Never Satisfied A Cultural History of DietsFantasies and Fat The Free Press New York NY USA 1986

[7] Medico-Actuarial Mortality Investigation vol 1 Association ofLife Insurance Medical Directors The Actuarial Society ofAmerica New York NY USA 1912

[8] L IDublin andA J LothaTwenty-Five Years ofHealth ProgressA Study of the Mortality Experience among the IndustrialPolicyholders of the Metropolitan Life Insurance Company 1911to 1935 Metropolitan Life Insurance New York NY USA 1937

[9] Ideal weight for women Statistical bulletin of the MetropolitanLife Insurance Company 1943

[10] Metropolitan Life Insurance Company ldquoIdeal weights for menrdquoStatistical Bulletin of the Metropolitan Life Insurance Companyvol 23 pp 6ndash8 1942

Journal of Obesity 9

[11] Metropolitan Life Insurance Company ldquoNew weight standardsfor men and womenrdquo Statistical Bulletin-Metropolitan LifeInsurance Company vol 40 pp 1ndash4 1959

[12] Build and Blood Pressure Study vol 1 Society of ActuariesChicago Ill USA 1959

[13] Metropolitan Life Insurance Company ldquoMetropolitan heightand weight tablesrdquo Statistical Bulletin (Metropolitan Life Insur-ance Company) vol 64 pp 1ndash19 1983

[14] Build Study 1979 Society of Actuaries and Associations of LifeInsurance Medical Directors Chicago Ill USA 1980

[15] WHO ldquoPhysical status the use and interpretation of anthro-pometryrdquo Report of a WHO Expert Committee WHO Tech-nical Report Series 854 World Health Organization GenevaSwitzerland 1995

[16] US Department of Agriculture and US Department of Healthand Human Services Dietary Guidelines for Americans 2010US Government Printing Office Washington DC USA 2010

[17] H C Fish The Agentrsquos Manual of Life Assurance Mutual LifeInsurance Company of New York New York NY USA 1867

[18] US Department of Agriculture and US Department of Healthand Human Services Nutrition and Your Health DietaryGuidelines for Americans US Government Printing OfficeWashington DC USA 1980

[19] M A Quetelet A Treatise on Man and the Development of HisFaculties William and Robert Chambers Edinburgh UK 1842

[20] J Hutchinson ldquoOn the capacity of the lungs and on therespiratory functions with a view of establishing a precise andeasy method of detecting disease by the spirometerrdquo Medico-Chirurgical Transactions (London) vol 29 pp 137ndash161 1846

[21] ldquoObesity in perspectiverdquo in Fogarty International Center Serieson PreventiveMedicine G Bray Ed vol 2 ofDHEWPublicationno (NIH) 75-708 part 1 1975 httpssearchworksstanfordeduview2520869

[22] ldquoHealth implications of obesity National Institutes of Healthconsensus development conference statementrdquo Annals of Inter-nal Medicine vol 103 no 1 pp 147ndash151 1985

[23] ldquoHealth implications of obesity National institutes of healthconsensus development conference statementrdquo Annals of Inter-nal Medicine vol 103 no 6 part 2 pp 1073ndash1077 1985

[24] US Department of Agriculture and US Department of Healthand Human Services Nutrition and Your Health DietaryGuidelines for Americans Home and Garden Bulletin no 232US Government Printing Office Washington DC USA 1985

[25] US Department of Agriculture and US Department of HealthandHuman ServicesNutrition and YourHealth Dietary Guide-lines for Americans vol 232 of Home and Garden Bulletin USGovernment Printing Office Washington DC USA 1990

[26] WHO ldquoObesity preventing and managing the global epi-demicrdquo WHO Technical Report Series 894 World HealthOrganization Geneva Switzerland 2000

[27] US Department of Agriculture and US Department of Healthand Human Services Nutrition and Your Health DietaryGuidelines for Americans US Government Printing OfficeWashington DC USA 1995

[28] Congressional Record Public law 101ndash445 National NutritionMonitoring and Related Research Act of 1990 October 1990[Congressional Record vol 136 House Report no 101 (Com-mittee on Agriculture)] 1990

[29] WHOIASOIOTF The Asia-Pacific Perspective RedefiningObesity and Its Treatment Health Communications Mel-bourne Australia 2000

[30] WHO Expert Consultation ldquoAppropriate body-mass index forAsian populations and its implications for policy and interven-tion strategiesrdquoTheLancet vol 363 no 9403 pp 157ndash163 2004

[31] J Yudkin ldquoObesity a report of the royal college of physiciansrdquoJournal of the Royal Society of Medicine vol 76 no 6 pp 531ndash532 1983

[32] The Secretary of Health and Human Services Charter 2015Dietary Guidelines Advisory CommitteeThe Secretary ofHealthand Human Services Washington DC USA 2015

[33] W F Kemsley W Z Billewicz and A M Thomson ldquoA newweight-for-height standard based on British Anthropometricdatardquo British Journal of Preventive amp Social Medicine vol 16 pp189ndash195 1962

[34] R J Kuczmarski and K M Flegal ldquoCriteria for definition ofoverweight in transition background and recommendations forthe United Statesrdquo The American Journal of Clinical Nutritionvol 72 no 5 pp 1074ndash1081 2000

[35] R J Jarrett ldquoIs there an ideal body weightrdquo British MedicalJournal vol 293 no 6545 pp 493ndash495 1986

[36] K M Flegal C J Tabak and C L Ogden ldquoOverweightin children Definitions and interpretationrdquo Health EducationResearch vol 21 no 6 pp 755ndash760 2006

[37] T J Cole M C Bellizzi K M Flegal and W H DietzldquoEstablishing a standard definition for child overweight andobesity worldwide international surveyrdquo The British MedicalJournal vol 320 no 7244 pp 1240ndash1243 2000

Submit your manuscripts athttpwwwhindawicom

Stem CellsInternational

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

MEDIATORSINFLAMMATION

of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Behavioural Neurology

EndocrinologyInternational Journal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Disease Markers

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

BioMed Research International

OncologyJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Oxidative Medicine and Cellular Longevity

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

PPAR Research

The Scientific World JournalHindawi Publishing Corporation httpwwwhindawicom Volume 2014

Immunology ResearchHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Journal of

ObesityJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Computational and Mathematical Methods in Medicine

OphthalmologyJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Diabetes ResearchJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Research and TreatmentAIDS

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Gastroenterology Research and Practice

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Parkinsonrsquos Disease

Evidence-Based Complementary and Alternative Medicine

Volume 2014Hindawi Publishing Corporationhttpwwwhindawicom

2 Journal of Obesity

2 What Is Obesity

Hippocrates (460 BCndash370 BC) described the health forhuman body as a balance of four humors (fluids) blood blackbile yellow bile and phlegm and any deficiencies or extraswere considered causes of diseases [4] Obesity was definedas the surplus of humors [4] For a big part of human historyextra weight was considered as an indication of good healthaswell aswealth and prosperityHippocrateswas the first whorealized that obesity leads to infertility and earlymortality [5]It took more than two thousand years to test his hypothesesscientifically and evaluate how ldquosurplus of humorsrdquo relates todifferent health outcomes and early deaths

The weight measurement and evaluation criteria arenecessary to define overweight and obesity In 1885 intro-duction of a penny scale first in Germany then in the UnitedStates allowed measuring the body weight to the nearestpound [6] Since then a new era for weight assessments andsearch for ldquohealthyrdquo weight started In the beginning of 20thcentury a low body weight was a concern because of threatof pneumonia and tuberculosis especially for young andunderweight adults [7] Healthy weight became the criteriafor the individualrsquos enrollment into the insurance policies [7ndash12] The question of ldquoidealrdquo weight and the acceptable level ofdeviation from ldquoidealrdquo became the most important questionsfor insurance companies [7ndash12] Overweight was defined asweight that exceeded the threshold from the reference valuewhere reference value was derived from the distribution ofpopulation Based on observed association of body weightwith mortality the Metropolitan Life Insurance Company(MLIC) was able to develop the standard tables for ldquoidealrdquo(MLIC 1942) [9 10] and then ldquodesirablerdquo weight (MLIC 1959)[11 12] and finally just ldquoheight to weightrdquo tables (MLIC1983) [13 14] Those standard tables became the platform fordevelopment of current definition for underweight normaloverweight and obese individuals based on the body massindex (BMI) cut-offs [15 16]

3 Measurements of Obesity

One of the ways to assess overweight and obesity is tocompare the individualrsquos weight versus the reference valuedefined as the average population weight and another wayis to compare it with the weight standards that derivedfrom the relationship between body weight and mortalityor morbidity outcomes The background of developmentreference or ldquoaveragerdquo tables is outlined in Section 31 Theprocess of how tables of ldquoaveragerdquo weight were transformedinto the ldquoidealrdquo weight standards tables based on the lowestrate of mortality is described in Section 32 The historicalbackground of development of both is summarized inTable 3

31 ldquoNormal Manrdquo and the ldquoAveragerdquo Weight Tables Belgianastronomer and mathematician Adolphe Quetelet (1796ndash1874) was fascinated by the probability theory and passion-ately applied probability calculus into the physical charac-teristics of human body [19] His idea was to demonstratethat normal Gaussian distribution can be applied to physicalattributes of humans and he was looking for the ldquonormrdquo [19]

Table 1 Table of height and weight [17 page 139]

Height Weight (pounds)Feet Inches5 1 1205 2 1255 3 1305 4 1355 5 1405 6 1435 7 1455 8 1485 9 1555 10 1605 11 1656 infin 170

In 1831-32 Quetelet conducted what has been considered thefirst cross-sectional study of newborns and children based ontheir growth in height and weight [19] Adolphe Queteletrsquoscross-sectional studies of human development revealed thatweight grows as a cube of babyrsquos height during the firstyear of life and then as a square of height until pubertyand almost stops after the age of twenty-five [19] In 1835Quetelet published a book entitled ldquoA Treatise on Man andthe Development of His Aptitudesrdquo with the conclusion thatindividualrsquos weight increases as a function of the square oftheir height and introduced the anthropometric index asweight in kilograms divided by the square of the height inmeters which is now known as Quetelet Index [19 years 1835and 1842 English translation] Adolphe Quetelet was the firstwho developed the table of the ldquoaverage weightrdquo at ages 2030 40 50 and 60 for a sample of Belgian men and women[7 19]

In 1846 Hutchinson a British surgeon published a tableof the ldquoaveragerdquo weights of 30-year-old men for each inch ofheight from5 feet 1 inch to 6 feet at age of 30 based on statisticsof 2650 Englishmen [7 20] This table became the referencefor English population and was used by the life insurancecompanies as a guide to evaluate applicants [7 17]

In 1867 Fish published ldquoThe Agentrsquos Manual of LifeAssurancerdquo by the Mutual Life Insurance Company of NewYork [17] Table of height and weight (Table 1 [17 page139]) adopted English reference for American people basedon reviews from Minturn Post and Isaac L Kip who weremedical examiners for the Mutual Life Insurance CompanyofNewYork [17]The reference table for American populationldquodiffers slightlyrdquo from the English ones set by Hutchinson andoffered ldquowhat the best authorities regard as themost desirableproportion of the height of individuals to their weightrdquo [17]

In 1889 the Actuarial Society of America and the Asso-ciation of Life Insurance Medical Directors of America werefounded which made possible a uniformed approach to theindustry-wide height and weight tables [7] In 1912 Medico-Actuarial Mortality Investigation published the statistics ofheight and weight of insured people and set up a goal ldquotoprovide an accurate Standard Table of Heights and Weightsand to determine the influence of build on longevityrdquo [7]

Journal of Obesity 3

The whole process of development of standard weight tableswith major milestones is summarized in Section 32 andTable 3

32 Standard Tables of ldquoIdealrdquo Weight First tables of ldquoidealrdquoweights were developed by Dublin and Lotha (1882ndash1969) astatistician and vice president of the Metropolitan Life Insur-anceCompany (MLIC) [8]Thedata from approximately fourmillion MLIC policyholders from 1911 to 1935 were utilized[8] The main criterion for ldquoidealrdquo weight was longevity [8]Dublin and Lotha grouped policyholders into categories bysex height and weights but they could not fit the numbersinto normal curve until they divided the studied populationfurther into the three types of body frames small mediumand large [8] From the prospective of insurance the ldquobadweightrdquo was considered to be 20ndash25 with morbid obesityat 70ndash100 above the ldquoidealrdquo weight for a given frame [8]The ldquo1942-43 Metropolitan Height and Weight Tablesrdquo werecreated based on Dublin and Lotha work and became thenational standards for ldquoidealrdquo body weight [9 10] Thosetables were close representation of the longevity of Americanpopulation but contained little information about trend andcauses of mortality [9 10]

In 1959 ldquoThe Build and Blood Pressure Studyrdquo was con-ducted by the Society of Actuaries with collaboration of 26insurance companies to determine the mortality of insuredpersons according to variations in body build and bloodpressure [12 14] The weights were derived from data ofpeople with lowest mortality who were insured between 1935and 1953 and followed to 1954 in the United States andCanada [12] Measured heights and weights were of peoplewearing ldquoindoor clothing and shoesrdquo and included 20 ofself-reported values [12] ldquoFrame sizerdquo for this study was notbased on measurement of skeletal dimensions but arbitrarilydivided the distribution of relative weights on the assumptionthat skeletal size was associated with a personrsquos position inthat distribution [12] The association between body weightand mortality particularly from cardiovascular diseases wasdemonstrated and MLIC 1959 weight tables were createdwhere ldquoideal weightrdquo was replaced by the ldquodesirable weightrdquo[11]

In 1973 the Fogarty International Center Conference onObesity recommended guidance for body weight based onthe updates from the MLIC 1959 ldquodesirablerdquo weight tables[21] The updates meant creation of ldquoacceptable rangerdquo ofweight for a particular height by the rule that for men andwomen for each inch of height set up the range of weightwhere the weight in the lower limit of the small frame and theweight in the upper limit of the large frame form the range ofweights for the standards [21 31] The ldquoacceptable rangerdquo forweight was converted into the suggested body mass index as201ndash250 for men and 187ndash238 for women [21] These tableswere adopted in the report of obesity by Royal College ofPhysicians in 1983 [31]

In 1979 the second study of ldquoThe Build and BloodPressure Studyrdquo produced the revised tables based on themortality of insured people from 1950 to 1972 where ldquodesir-ablerdquo weights were higher than those in previous study [14]Based on the data from new study the MLIC 1959 tables

Table 2 Range of acceptable body weight [18]

Height (feet-inches) Men (pounds) Women (pounds)410158401010158401015840 92ndash119410158401110158401015840 96ndash12951015840010158401015840 96ndash12551015840110158401015840 99ndash12851015840210158401015840 112ndash141 102ndash13151015840310158401015840 115ndash144 105ndash13451015840410158401015840 118ndash148 108ndash13851015840510158401015840 121ndash152 111ndash14251015840610158401015840 124ndash156 114ndash14651015840710158401015840 128ndash161 118ndash15051015840810158401015840 132ndash166 122ndash15451015840910158401015840 136ndash170 126ndash150510158401010158401015840 140ndash174 130ndash163510158401110158401015840 144ndash179 134ndash16861015840010158401015840 148ndash184 138ndash17361015840110158401015840 152ndash18961015840210158401015840 156ndash19461015840310158401015840 160ndash19961015840410158401015840 164ndash204Note height without shoes and weight without clothes

for ldquodesirablerdquo weight were replaced by MLIC 1983 tables ofldquoheight and weightrdquo [13]

Overweight and obesity are the nutrition-related disor-ders which are caused by the accumulation of extra fat aswas stated by the Department of Health and Human Services(HHS) and the Department of Agriculture (USDA) whichwere responsible for issuing the ldquoDietary Guidelines for Amer-icansrdquo in 1980 and for updating the document every 5 years[32] The goal of the document was to provide nutritionaland dietary information and guidance for general public In1980 US Department of Agriculture and US Department ofHealth Education and Welfare published the first edition ofnutritional ldquoDietary Guidelines for Americansrdquo and advisedthe public based on current knowledge of the relationshipof diet to health and disease [18] The guidance includeda table with suggested body weight based on the tablesrecommended by Fogarty International Center Conferenceon Obesity with the adjustments for height and weight [18]Adjustment for height was done as 1 or 2 inches (254 and508 cm) for shoes and 10 lbndash6 lb for clothes (Table 2) [18 3334]

The National Institutes of Health Consensus Develop-ment Conference on the Health Implications of Obesityapplied criteria for defining overweight severe overweightobesity and severe obesity to the National Health andNutrition Examination Survey 1976ndash80 (NHANES II) data[22] ldquoOverweightrdquo was defined by a BMI (body massindex = weight in kilograms divided by weight in meterssquared) ge85th percentile with ldquosevere overweightrdquo ge95thpercentile of 20-year-old to 29-year-old men and women[22] ldquoObesityrdquo and ldquosevere obesityrdquo were defined using thesame criteria only the sum of the triceps and subscapularskinfold thicknesses instead of the body mass index [22]The

4 Journal of Obesity

Table3Develop

mento

fweightstand

ardtables

Year[ref]

Author

Criterialowast

Popu

latio

nScreening

Develo

pment

Milesto

neoutcome

1842

[19]

Quetelet

Tablesw

eighttoheight

byage

grou

p203040

50and60

Belgianmen

andwom

enWith

clothes

and

shoes(as

is)

Develo

pedatableo

fthe

averagew

eight

byagesfora

sampleo

fBelg

ianmen

andwo

men

ldquoAverage

weightrdquo

Belgian

1846

[20]

Hutchinson

Tablesw

eighttoheight

for3

0yo

En

glish

men

from

51015840110158401015840

to6feet

5feet1inchto

6feet30y

o

2650En

glish

men

Averagew

eightsof

30yo

men

for

each

inch

ofheight

from

51015840110158401015840

to6feet

ldquoAverage

weightrdquo

English

1867

[17]

Fish

Tablesw

eighttoheight

for3

0yo

American

men

from

51015840110158401015840

to6feet

American

MedicalRe

view

ofEn

glish

Tables

(from

John

Hutchinson)

TheA

gentrsquosManua

lofL

ifeAssurance

ldquoAverage

weightrdquo

American

1912

[7]

TheA

ssociatio

nof

LifeInsurance

MedicalDire

ctors

andtheA

ctuaria

lSo

cietyof

America

Tablesbased

onrateofmortality

weightb

yheight

tables

form

enandwom

enby

age

Mortalityforinsured

popu

latio

n

Season

alconsiderationto

have

thes

ame

clothes

andshoes

ReportofTh

eJoint

Committee

onTh

eMedico

-Actua

rial

MortalityInvestigationldquoA

verage

weightm

ayno

thavethe

lowest

mortalityrdquomdashwhatisidealweight

ldquoIdealweightrdquobasedon

longevity

1937

[8]

Dub

linandLo

tha

(1882ndash1969)

Metropo

litan

Life

InsuranceC

ompany

fram

e[8]1937

Tablesw

eighttoheight

bysexand

body

frame

sim4millionpeop

leinsured

byMetLife1911ndash

1935

Heightwith

street

shoesW

eighton

lyindo

orclo

thes

Dub

lindividedthea

verage

weights

into

threetypes

ofbo

dyfram

essmall

mediumand

largeF

rom

the

prospectiveo

finsurancethe

bad

weightw

asconsidered

tobe

20ndash25

with

morbidob

esity

at70ndash100above

theldquo

idealrdquo

ldquoIdealweightrdquo

(based

onlowest

mortalityforinsured

popu

latio

n)

1942-3

[910]

Metropo

litan

Life

InsuranceC

ompany

(MLIC)

Tablesw

eightb

yheight

bysexand

body

fram

eLo

ngevity

criteria

weight

maintainedatthes

amelevelas

25yo

with

sameh

eightand

body

fram

e

Prop

osed

tables

forldquoideal

weightrdquoform

enand

wom

engt25

yobyfram

esiz

e

Heightwith

street

shoes

Weighton

lyindo

orclo

thes

Natio

nalStand

ards

forW

eight

bysexandbody

frameM

LIC1942-43

Obesity20aboveidealweight

ldquoIdealweightrdquo

1959

[1112]

TheB

uild

andBloo

dPressure

Stud

yTablesw

eightb

yheight

bysexand

body

fram

e

USandCa

nada-in

sured

(from

26lifeinsurance

companies)p

eople

1935ndash195420

self-repo

rted

Streetshoesa

ndindo

orclo

thes

RevisedMLIC1959

tables

Stan

dard

Tablesbasedon

associa

tion

with

mortality(

notm

orbidity)

distrib

utionof

weighttoheight

associationwith

minim

ummortality

(lowestd

eath

rate)O

besity20above

idealw

eight

ldquoDesira

blew

eightrdquo

1975

[21]

FogartyCenter

Con

ferenceo

nObesity

Rangeo

facceptablew

eight

SuggestedrangeB

MI

201ndash

250form

en187ndash

238forw

omen

Basedon

MLIC1959

Adjuste

dstr

eet

shoesa

ndindo

orclo

thes

Guidan

ceforb

odyw

eight

Rangeo

facceptable

weight

Journal of Obesity 5

Table3Con

tinued

Year[ref]

Author

Criterialowast

Popu

latio

nScreening

Develo

pment

Milesto

neoutcome

1979

[1314]

TheB

uild

andBloo

dPressure

Stud

ysecond

study

Tablesw

eightb

yheight

bysexand

body

fram

e

Insuredpeop

le1950ndash1972

10self-repo

rted

Streetshoesa

ndindo

orclo

thes

RevisedMLIC1983

tables

ldquoHeig

httowe

ight

tablesrdquo

1980

[18]

USDepartm

ento

fAgriculture

andUS

Departm

ento

fHealth

Edu

catio

nandWelfare

Adjuste

drangeo

facceptable

weighto

fage

andheight

specific

MLIC59

Adjuste

dstr

eet

shoesa

ndindo

orclo

thes

DietaryG

uidancefor

America

ns(1s

tedition)

Rangeo

facceptable

weight

from

ldquodesira

blerdquo

weighttables

1985

[2223]NationalInstituteo

fHealth

ldquoOverw

eightrdquoB

MIge

85th

percentileldquosevereo

verw

eightrdquo

BMIge

95th

percentileo

f20-year-oldto

29-year-oldmen

andwom

enldquoObesityrdquo

andldquosevere

obesity

rdquosam

efor

thes

umof

the

tricepsa

ndsubscapu

larskinfold

thickn

esses

NHANES

II1976ndash80

Men

andwom

en20ndash29yearso

ld

Criteria

matched

forrange

ofacceptableweight

notge

20of

desir

ableweight

form

idpo

into

fmedium-build

person

MLIC

83

Guidan

ceforb

odyw

eight

Overw

eight-o

besityBM

Ige278form

enge273forw

omen

SuggestedrangeB

MIfor

malesand

females

264ndash285(M

LIC59)2

72ndash269(MLIC

83)

Rangeo

facceptable

weight

1985

[24]

USDepartm

ento

fAgriculture

andUS

Departm

ento

fHealth

Edu

catio

nandWelfare

Overw

eighttranslatedto

BMIfor

mensim25-26andforw

omen

sim24-25

MLIC59

DietaryG

uidancefor

America

ns(2nd

edition)

Desira

blew

eight

1990

[25]

USDepartm

ento

fAgriculture

andUS

Departm

ento

fHealth

Edu

catio

nandWelfare

BMIge

25fora

ges19ndash

34andge27

fora

gesge

35years

Alladults(both

sexesc

ombined)

by2ageg

roup

s

DietaryG

uidancefor

America

ns(3rd

edition)translated

inBM

Ige25

for

ages

19ndash34andge27

fora

gesge

35years

Unhealthyw

eight

1995

[15]

2000

[26]

World

Health

Organization(W

HO)

Mortalitycurve

Internationald

ata

Mortalitycurves

forB

MIsele

ction

Internationa

lClassificationofWeig

htInternationa

lClassifi

catio

nofWeig

htbasedon

BMIlevel

1995

[27]

USDepartm

ento

fAgriculture

andUS

Departm

ento

fHealth

Edu

catio

nandWelfare

BMIge

25fora

llages

Alladults(bothsexes

combined)

fora

llages

Noshoesno

clothes

DietaryG

uidancefor

America

ns(4th

edition)

Health

yweig

ht

1998

[2]

NationalInstituteo

fHealth

(NIH

)and

NationalH

eartLun

gandBloo

dInstitute

(NHLB

I)

Relatio

nof

BMIand

riskof

morbidityandmortality

RCTandepidem

iological

studies

Clinica

lGuidelin

eson

the

Identifi

catio

nEvaluatio

nan

dTreatm

entofO

verw

eight

andObesity

inAd

ults

Assessm

enta

ndtre

atmentm

anagem

ent

ofoverwe

ighta

ndobesity

6 Journal of Obesity

Table3Con

tinued

Year[ref]

Author

Criterialowast

Popu

latio

nScreening

Develo

pment

Milesto

neoutcome

2010

[16]

USDepartm

ento

fAgriculture

andUS

Departm

ento

fHealth

Edu

catio

nandWelfare

WHOInternationalC

lassificatio

nof

Weightb

ased

onBM

Ilevelwas

adop

tedforU

Spo

pulatio

nUSA

Matches

with

WHOandNIH

andNHLB

Icriteria

DietaryG

uidancefor

America

ns(7th

edition)lowastlowast

BMIclassification

matcheswith

WHOand

NIH

andNHLB

I1998

lowastCr

iteria

fortablegeneratio

nlowastlowastNexteditio

nisexpected

in2015

ldquoNationalN

utritionMon

itorin

gandRe

lated

Research

Acto

f1990rdquomdashPu

blicLaw101ndash445Title

IIISectio

n301sta

tedthatarepo

rtentitledldquoD

ietaryGu

idelinesfor

America

nsrdquos

hallcontainnu

trition

alanddietary

inform

ationandguidelines

forthe

generalpub

licandldquoshallbe

prom

oted

byeach

Federalagencyin

carrying

outany

Federalfoo

dnu

trition

orh

ealth

programrdquo[28]

Journal of Obesity 7

numbers came to the criteria of defining ldquooverweightrdquo as BMIge278 kgm2 for men and BMI ge273 for women [22] Thesecriteria matched with 20 or more above the ldquodesirablerdquoweight in the MLIC 1983 tables (from midpoint of the rangefor a medium-build person) [22] These definitions becamewidely accepted as the standards [22] Nevertheless numbersfor ranges of acceptable ldquonormalrdquo BMI were different fromthose based on the version of standard tables for example forMLIC 1959 264 (men) and 285 (women) and forMLIC 1983272 (men) and 269 (women) [23] Moreover the recom-mended requirement differed from the guidelines set up byFogarty Center and the Royal College of Physicians [21 35]Such discrepancies in the guidance pointed out the technicalproblems of weight to height tables the discrepancies ofmeasurements (shoes clothes and approximately 20 self-reported data in MLIC 1959 and 10 in MLIC 1983) andpopulation selection [35] It brought up an urgent need tostandardize definition of overweight and obesity and thesearch for weight to height index of body weight started

In 1985 the Department of Health and Human Services(HHS) and the Department of Agriculture (USDA) issuedthe second edition of ldquoDietary Guidelines for Americansrdquo [24]That document used the ldquodesirablerdquo weight to height tablesfromMLIC 1959 and translated the numbers into overweightlevel of BMI for men sim25-26 and for women sim24-25 [24 34]In the 1990 third edition tables for men and women werecombined into one and presented by two age groups whereldquounhealthyrdquo weight was translated into BMI ge 25 for ages 19ndash34 and ge27 for ages ge35 years [25 34]

In 1990 the ldquoNational Nutrition Monitoring and RelatedResearch Act of 1990rdquo Public Law 101ndash445 Title IIISection 301 stated that a report entitled ldquoDietary Guidelinesfor Americansrdquo shall contain nutritional and dietary informa-tion and guidelines for the general public and be publishedat least every five years [28] Each such report ldquoshall bepromoted by each Federal agency in carrying out any Federalfood nutrition or health programrdquo [28] Basically the lawstated that the definition of healthy weight or overweightfrom the Dietary Guidelines for Americans should be usedby the constituent Federal agencies [28]

In Geneva in 1995 WHO Expert Committee on PhysicalStatus published technical reportThe Use and Interpretationof Anthropometry [15] It was acknowledged that the basicanthropometry measurements of human body are weightand height [15] It was recommended to combine twobasic measurements weight and height into the body massindex (weightheight2) or ponderal index (weightheight3)for adults and three anthropometric indexes with consider-ation of age were described for children weight for heightheight for age and weight for age [15] The WHO ExpertCommittee on Physical Status proposed to classify differentlevels of BMI with cut-off points of 25 30 and 40 based onldquoarbitrarymethod of association betweenBMI andmortalityrdquo[15] WHO Expert Committee on Physical Status refer-enced the meta-analysis performed by Troiano et al whichincluded 17 studies with 37 substudies with 350000 menand gt38000 deaths plus six studies with 12 substudies with250000 women and 13700 deaths and presented the U-shapemortality rates that sharply increased when BMI lt185 and

Table 4 International classification of adults based on body massindex

Classification BMI (kgm2)Cut-off points Additional cut-off points

Underweight lt1850 lt185Severe thinness lt1600 lt160Moderate thinness 1600ndash1699 1600ndash1699Mild thinness 1700ndash1849 1700ndash1849

Normal 1850ndash2499 1850ndash22992300ndash2499

Overweight ge2500 ge2500

Preobese 2500ndash2999 2500ndash27492750ndash2999

Obese ge3000 ge3000

Class I 3000ndash3499 3000ndash32493250ndash3499

Class II 3500ndash3999 3500ndash37493750ndash3999

Class III ge4000 ge4000Source fromWHO 1995 WHO 2000 and WHO 2004 [15 26 29 30]

gt300 kgm2 with the acceptable BMI range as 185ndash2500 [15page 322] The WHO experts underscored that the cut-offswere chosen arbitrarily based on the ldquovisual inspection ofthe relationship between BMI and mortalityrdquo [15] curve forexample ldquothe cut-off of 30 is based on the point of flexionof the curverdquo [15] The authors suggested that this methodshould be revised in the future in terms of BMI associationwith health risk [15]

In 1995 the next step was taken to combine not justboth sexes but also age groups where ldquohealthyrdquo weight wastranslated in BMI ge25 for all adults in the fourth editionof ldquoDietary Guidelines for Americansrdquo [27] The report usedWHO criteria for publishing healthy weight ranges for menand women by each inch of height [27] The edition was veryimportant because it led to publishing the prevalence andtrends on overweight (BMI ge 25) preobese (BMI 250ndash299)class 1 (BMI 300ndash349) class 2 (BMI 350ndash399) and class3 (BMI ge 400) obese in the United States data from 1960to 1994 (NHANES I II and III) for first time to facilitatecomparison with international data [2]

Clinical Guidelines on the Identification Evaluation andTreatment of Overweight and Obesity in Adults (NIH Septem-ber 1998) defined overweight as a body mass index (BMI) of25 to 299 kgm2 and obesity as a BMI of ge30 kgm2 [2] Thepanel of experts came to this classification based on evidencefrom approximately 394 randomized controlled trials (RCTs)and multiple observational studies about BMI and risk ofmorbidity and mortality [2] The classification matched withone suggested by WHO [2 15]

In 2000 World Health Organization (WHO) definedoverweight and obesity as ldquothe disease in which excess bodyfat has accumulated to such an extent that health may beadversely affectedrdquo [26] and underscored that the practicaldefinition of obesity is based on the level of body massindex (BMI) [15 26]Themost recent version of international

8 Journal of Obesity

Table 5 Overweight and obese children and adolescents [16]

Category Children and adolescents (BMI for agepercentile rangelowast) Adults (BMI)

Underweight Less than the 5th percentile Less than 185 kgm2

Healthy weight 5th percentile to less than the 85th percentile 185 to 249 kgm2

Overweight 85th percentile to less than the 95th percentile 250 to 299 kgm2

Obese Equal to or greater than the 95th percentile 300 kgm2 or greaterlowastGrowth charts are available at httpwwwcdcgovgrowthcharts

classification for adults developed by WHO is presented inTable 4 [15 26]

BMI has never been a perfect index for children becauseit correlates with height In the United States Centers forDisease Control and Prevention (CDC) 2000 used fivenationally representative surveys to develop BMI charts forchildren in the United States the National Health Examina-tion Surveys (NHES) II and III in the 1960s the NationalHealth and Nutrition Examination Surveys (NHANES) I andII in the 1970s and NHANES III for the period of 1988ndash1994 Those charts included gender-specific BMI by singlemonth of age curves of growth Currently they are used inthe United States for children who are 2ndash19 years old todefine ldquooverweightrdquo as BMI ge95th percentile or ldquoat risk foroverweightrdquo if BMI is between 85th and 95th percentiles[26 36]

International surveys of six large and nationally repre-sentative cross-sectional growth studies from Brazil GreatBritain Hong Kong Netherlands Singapore and the UnitedStates were used by International Obesity Task Force (IOTF)to establish the cut-off points for overweight and obeseamong children and adolescents [37] In summary partic-ipants of IOTF agreed to link childhood overweight andobesity to the cut-offs for adults Based on each of the surveyspercentile curves were drawn in such a way that they passedthrough BMI cut-off points of 25 and 30 kgm2 at age of18 years and the resulting curves were averaged by age andgender to provide cut-off points for 2 through 18 years of age[37] This way less arbitrary and more internationally basedcut-offs were proposed [37]

In the current edition ofDietaryGuidelines for Americans2010 the BMI cut-offs are consistent with internationallyrecommended [16] By the Public Law 101ndash445 Title IIISection 301 all Federal agencies have made the transitionto define overweight and obesity as a BMI consistent withrecommendations in the current edition ofDietaryGuidelinesfor Americans [16 28] The table of weight category basedon BMI level from Dietary Guidelines for Americans 2010 ispresented in Table 5 [16]

4 Summary

There is nationwide and global epidemic of obesity As thefirst step to conquer a problem the concept of obesity shouldbe clearly understood through the historical process that ledto the worldwide accepted standard definition This paperpresents the history of developing current standard definitionof overweight and obesity Understanding the roots will lead

to the successful research on obesity with a goal to defeatnational and global epidemic

Competing Interests

The author declares that there are no competing interests

Acknowledgments

The author thanks Drs Michael Szarek Michael Walsh andElizabeth Helzner for assistance with development of thisproposal

References

[1] US Department of Health and Human Services The SurgeonGeneralrsquos Call to Action to Prevent and Decrease Overweight andObesity US Department ofHealth andHuman Services PublicHealth Service Office of the Surgeon General Rockville MdUSA 2001

[2] National Institutes of Health ldquoClinical guidelines on the identi-fication evaluation and treatment of overweight and obesity inadults-the evidence reportrdquoObesity Research vol 6 supplement2 pp 51Sndash209S 1998

[3] ldquoNutrition and overweightrdquo in Healthy People 2010 chapter 19pp 1ndash15 Food and Drug Administration National Institutes ofHealth Hyattsville Md USA 2001 httpwwwcdcgovnchsdatahpdata2010hp2010 final review focus area 19pdf

[4] H Christopoulou-Aletra andN Papavramidou ldquoMethods usedby the Hippocratic physicians for weight reductionrdquo WorldJournal of Surgery vol 28 no 5 pp 513ndash517 2004

[5] D Haslam ldquoObesity a medical historyrdquoObesity Reviews vol 8supplement 1 pp 31ndash36 2007

[6] H Schwartz Never Satisfied A Cultural History of DietsFantasies and Fat The Free Press New York NY USA 1986

[7] Medico-Actuarial Mortality Investigation vol 1 Association ofLife Insurance Medical Directors The Actuarial Society ofAmerica New York NY USA 1912

[8] L IDublin andA J LothaTwenty-Five Years ofHealth ProgressA Study of the Mortality Experience among the IndustrialPolicyholders of the Metropolitan Life Insurance Company 1911to 1935 Metropolitan Life Insurance New York NY USA 1937

[9] Ideal weight for women Statistical bulletin of the MetropolitanLife Insurance Company 1943

[10] Metropolitan Life Insurance Company ldquoIdeal weights for menrdquoStatistical Bulletin of the Metropolitan Life Insurance Companyvol 23 pp 6ndash8 1942

Journal of Obesity 9

[11] Metropolitan Life Insurance Company ldquoNew weight standardsfor men and womenrdquo Statistical Bulletin-Metropolitan LifeInsurance Company vol 40 pp 1ndash4 1959

[12] Build and Blood Pressure Study vol 1 Society of ActuariesChicago Ill USA 1959

[13] Metropolitan Life Insurance Company ldquoMetropolitan heightand weight tablesrdquo Statistical Bulletin (Metropolitan Life Insur-ance Company) vol 64 pp 1ndash19 1983

[14] Build Study 1979 Society of Actuaries and Associations of LifeInsurance Medical Directors Chicago Ill USA 1980

[15] WHO ldquoPhysical status the use and interpretation of anthro-pometryrdquo Report of a WHO Expert Committee WHO Tech-nical Report Series 854 World Health Organization GenevaSwitzerland 1995

[16] US Department of Agriculture and US Department of Healthand Human Services Dietary Guidelines for Americans 2010US Government Printing Office Washington DC USA 2010

[17] H C Fish The Agentrsquos Manual of Life Assurance Mutual LifeInsurance Company of New York New York NY USA 1867

[18] US Department of Agriculture and US Department of Healthand Human Services Nutrition and Your Health DietaryGuidelines for Americans US Government Printing OfficeWashington DC USA 1980

[19] M A Quetelet A Treatise on Man and the Development of HisFaculties William and Robert Chambers Edinburgh UK 1842

[20] J Hutchinson ldquoOn the capacity of the lungs and on therespiratory functions with a view of establishing a precise andeasy method of detecting disease by the spirometerrdquo Medico-Chirurgical Transactions (London) vol 29 pp 137ndash161 1846

[21] ldquoObesity in perspectiverdquo in Fogarty International Center Serieson PreventiveMedicine G Bray Ed vol 2 ofDHEWPublicationno (NIH) 75-708 part 1 1975 httpssearchworksstanfordeduview2520869

[22] ldquoHealth implications of obesity National Institutes of Healthconsensus development conference statementrdquo Annals of Inter-nal Medicine vol 103 no 1 pp 147ndash151 1985

[23] ldquoHealth implications of obesity National institutes of healthconsensus development conference statementrdquo Annals of Inter-nal Medicine vol 103 no 6 part 2 pp 1073ndash1077 1985

[24] US Department of Agriculture and US Department of Healthand Human Services Nutrition and Your Health DietaryGuidelines for Americans Home and Garden Bulletin no 232US Government Printing Office Washington DC USA 1985

[25] US Department of Agriculture and US Department of HealthandHuman ServicesNutrition and YourHealth Dietary Guide-lines for Americans vol 232 of Home and Garden Bulletin USGovernment Printing Office Washington DC USA 1990

[26] WHO ldquoObesity preventing and managing the global epi-demicrdquo WHO Technical Report Series 894 World HealthOrganization Geneva Switzerland 2000

[27] US Department of Agriculture and US Department of Healthand Human Services Nutrition and Your Health DietaryGuidelines for Americans US Government Printing OfficeWashington DC USA 1995

[28] Congressional Record Public law 101ndash445 National NutritionMonitoring and Related Research Act of 1990 October 1990[Congressional Record vol 136 House Report no 101 (Com-mittee on Agriculture)] 1990

[29] WHOIASOIOTF The Asia-Pacific Perspective RedefiningObesity and Its Treatment Health Communications Mel-bourne Australia 2000

[30] WHO Expert Consultation ldquoAppropriate body-mass index forAsian populations and its implications for policy and interven-tion strategiesrdquoTheLancet vol 363 no 9403 pp 157ndash163 2004

[31] J Yudkin ldquoObesity a report of the royal college of physiciansrdquoJournal of the Royal Society of Medicine vol 76 no 6 pp 531ndash532 1983

[32] The Secretary of Health and Human Services Charter 2015Dietary Guidelines Advisory CommitteeThe Secretary ofHealthand Human Services Washington DC USA 2015

[33] W F Kemsley W Z Billewicz and A M Thomson ldquoA newweight-for-height standard based on British Anthropometricdatardquo British Journal of Preventive amp Social Medicine vol 16 pp189ndash195 1962

[34] R J Kuczmarski and K M Flegal ldquoCriteria for definition ofoverweight in transition background and recommendations forthe United Statesrdquo The American Journal of Clinical Nutritionvol 72 no 5 pp 1074ndash1081 2000

[35] R J Jarrett ldquoIs there an ideal body weightrdquo British MedicalJournal vol 293 no 6545 pp 493ndash495 1986

[36] K M Flegal C J Tabak and C L Ogden ldquoOverweightin children Definitions and interpretationrdquo Health EducationResearch vol 21 no 6 pp 755ndash760 2006

[37] T J Cole M C Bellizzi K M Flegal and W H DietzldquoEstablishing a standard definition for child overweight andobesity worldwide international surveyrdquo The British MedicalJournal vol 320 no 7244 pp 1240ndash1243 2000

Submit your manuscripts athttpwwwhindawicom

Stem CellsInternational

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

MEDIATORSINFLAMMATION

of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Behavioural Neurology

EndocrinologyInternational Journal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Disease Markers

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

BioMed Research International

OncologyJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Oxidative Medicine and Cellular Longevity

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

PPAR Research

The Scientific World JournalHindawi Publishing Corporation httpwwwhindawicom Volume 2014

Immunology ResearchHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Journal of

ObesityJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Computational and Mathematical Methods in Medicine

OphthalmologyJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Diabetes ResearchJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Research and TreatmentAIDS

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Gastroenterology Research and Practice

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Parkinsonrsquos Disease

Evidence-Based Complementary and Alternative Medicine

Volume 2014Hindawi Publishing Corporationhttpwwwhindawicom

Journal of Obesity 3

The whole process of development of standard weight tableswith major milestones is summarized in Section 32 andTable 3

32 Standard Tables of ldquoIdealrdquo Weight First tables of ldquoidealrdquoweights were developed by Dublin and Lotha (1882ndash1969) astatistician and vice president of the Metropolitan Life Insur-anceCompany (MLIC) [8]Thedata from approximately fourmillion MLIC policyholders from 1911 to 1935 were utilized[8] The main criterion for ldquoidealrdquo weight was longevity [8]Dublin and Lotha grouped policyholders into categories bysex height and weights but they could not fit the numbersinto normal curve until they divided the studied populationfurther into the three types of body frames small mediumand large [8] From the prospective of insurance the ldquobadweightrdquo was considered to be 20ndash25 with morbid obesityat 70ndash100 above the ldquoidealrdquo weight for a given frame [8]The ldquo1942-43 Metropolitan Height and Weight Tablesrdquo werecreated based on Dublin and Lotha work and became thenational standards for ldquoidealrdquo body weight [9 10] Thosetables were close representation of the longevity of Americanpopulation but contained little information about trend andcauses of mortality [9 10]

In 1959 ldquoThe Build and Blood Pressure Studyrdquo was con-ducted by the Society of Actuaries with collaboration of 26insurance companies to determine the mortality of insuredpersons according to variations in body build and bloodpressure [12 14] The weights were derived from data ofpeople with lowest mortality who were insured between 1935and 1953 and followed to 1954 in the United States andCanada [12] Measured heights and weights were of peoplewearing ldquoindoor clothing and shoesrdquo and included 20 ofself-reported values [12] ldquoFrame sizerdquo for this study was notbased on measurement of skeletal dimensions but arbitrarilydivided the distribution of relative weights on the assumptionthat skeletal size was associated with a personrsquos position inthat distribution [12] The association between body weightand mortality particularly from cardiovascular diseases wasdemonstrated and MLIC 1959 weight tables were createdwhere ldquoideal weightrdquo was replaced by the ldquodesirable weightrdquo[11]

In 1973 the Fogarty International Center Conference onObesity recommended guidance for body weight based onthe updates from the MLIC 1959 ldquodesirablerdquo weight tables[21] The updates meant creation of ldquoacceptable rangerdquo ofweight for a particular height by the rule that for men andwomen for each inch of height set up the range of weightwhere the weight in the lower limit of the small frame and theweight in the upper limit of the large frame form the range ofweights for the standards [21 31] The ldquoacceptable rangerdquo forweight was converted into the suggested body mass index as201ndash250 for men and 187ndash238 for women [21] These tableswere adopted in the report of obesity by Royal College ofPhysicians in 1983 [31]

In 1979 the second study of ldquoThe Build and BloodPressure Studyrdquo produced the revised tables based on themortality of insured people from 1950 to 1972 where ldquodesir-ablerdquo weights were higher than those in previous study [14]Based on the data from new study the MLIC 1959 tables

Table 2 Range of acceptable body weight [18]

Height (feet-inches) Men (pounds) Women (pounds)410158401010158401015840 92ndash119410158401110158401015840 96ndash12951015840010158401015840 96ndash12551015840110158401015840 99ndash12851015840210158401015840 112ndash141 102ndash13151015840310158401015840 115ndash144 105ndash13451015840410158401015840 118ndash148 108ndash13851015840510158401015840 121ndash152 111ndash14251015840610158401015840 124ndash156 114ndash14651015840710158401015840 128ndash161 118ndash15051015840810158401015840 132ndash166 122ndash15451015840910158401015840 136ndash170 126ndash150510158401010158401015840 140ndash174 130ndash163510158401110158401015840 144ndash179 134ndash16861015840010158401015840 148ndash184 138ndash17361015840110158401015840 152ndash18961015840210158401015840 156ndash19461015840310158401015840 160ndash19961015840410158401015840 164ndash204Note height without shoes and weight without clothes

for ldquodesirablerdquo weight were replaced by MLIC 1983 tables ofldquoheight and weightrdquo [13]

Overweight and obesity are the nutrition-related disor-ders which are caused by the accumulation of extra fat aswas stated by the Department of Health and Human Services(HHS) and the Department of Agriculture (USDA) whichwere responsible for issuing the ldquoDietary Guidelines for Amer-icansrdquo in 1980 and for updating the document every 5 years[32] The goal of the document was to provide nutritionaland dietary information and guidance for general public In1980 US Department of Agriculture and US Department ofHealth Education and Welfare published the first edition ofnutritional ldquoDietary Guidelines for Americansrdquo and advisedthe public based on current knowledge of the relationshipof diet to health and disease [18] The guidance includeda table with suggested body weight based on the tablesrecommended by Fogarty International Center Conferenceon Obesity with the adjustments for height and weight [18]Adjustment for height was done as 1 or 2 inches (254 and508 cm) for shoes and 10 lbndash6 lb for clothes (Table 2) [18 3334]

The National Institutes of Health Consensus Develop-ment Conference on the Health Implications of Obesityapplied criteria for defining overweight severe overweightobesity and severe obesity to the National Health andNutrition Examination Survey 1976ndash80 (NHANES II) data[22] ldquoOverweightrdquo was defined by a BMI (body massindex = weight in kilograms divided by weight in meterssquared) ge85th percentile with ldquosevere overweightrdquo ge95thpercentile of 20-year-old to 29-year-old men and women[22] ldquoObesityrdquo and ldquosevere obesityrdquo were defined using thesame criteria only the sum of the triceps and subscapularskinfold thicknesses instead of the body mass index [22]The

4 Journal of Obesity

Table3Develop

mento

fweightstand

ardtables

Year[ref]

Author

Criterialowast

Popu

latio

nScreening

Develo

pment

Milesto

neoutcome

1842

[19]

Quetelet

Tablesw

eighttoheight

byage

grou

p203040

50and60

Belgianmen

andwom

enWith

clothes

and

shoes(as

is)

Develo

pedatableo

fthe

averagew

eight

byagesfora

sampleo

fBelg

ianmen

andwo

men

ldquoAverage

weightrdquo

Belgian

1846

[20]

Hutchinson

Tablesw

eighttoheight

for3

0yo

En

glish

men

from

51015840110158401015840

to6feet

5feet1inchto

6feet30y

o

2650En

glish

men

Averagew

eightsof

30yo

men

for

each

inch

ofheight

from

51015840110158401015840

to6feet

ldquoAverage

weightrdquo

English

1867

[17]

Fish

Tablesw

eighttoheight

for3

0yo

American

men

from

51015840110158401015840

to6feet

American

MedicalRe

view

ofEn

glish

Tables

(from

John

Hutchinson)

TheA

gentrsquosManua

lofL

ifeAssurance

ldquoAverage

weightrdquo

American

1912

[7]

TheA

ssociatio

nof

LifeInsurance

MedicalDire

ctors

andtheA

ctuaria

lSo

cietyof

America

Tablesbased

onrateofmortality

weightb

yheight

tables

form

enandwom

enby

age

Mortalityforinsured

popu

latio

n

Season

alconsiderationto

have

thes

ame

clothes

andshoes

ReportofTh

eJoint

Committee

onTh

eMedico

-Actua

rial

MortalityInvestigationldquoA

verage

weightm

ayno

thavethe

lowest

mortalityrdquomdashwhatisidealweight

ldquoIdealweightrdquobasedon

longevity

1937

[8]

Dub

linandLo

tha

(1882ndash1969)

Metropo

litan

Life

InsuranceC

ompany

fram

e[8]1937

Tablesw

eighttoheight

bysexand

body

frame

sim4millionpeop

leinsured

byMetLife1911ndash

1935

Heightwith

street

shoesW

eighton

lyindo

orclo

thes

Dub

lindividedthea

verage

weights

into

threetypes

ofbo

dyfram

essmall

mediumand

largeF

rom

the

prospectiveo

finsurancethe

bad

weightw

asconsidered

tobe

20ndash25

with

morbidob

esity

at70ndash100above

theldquo

idealrdquo

ldquoIdealweightrdquo

(based

onlowest

mortalityforinsured

popu

latio

n)

1942-3

[910]

Metropo

litan

Life

InsuranceC

ompany

(MLIC)

Tablesw

eightb

yheight

bysexand

body

fram

eLo

ngevity

criteria

weight

maintainedatthes

amelevelas

25yo

with

sameh

eightand

body

fram

e

Prop

osed

tables

forldquoideal

weightrdquoform

enand

wom

engt25

yobyfram

esiz

e

Heightwith

street

shoes

Weighton

lyindo

orclo

thes

Natio

nalStand

ards

forW

eight

bysexandbody

frameM

LIC1942-43

Obesity20aboveidealweight

ldquoIdealweightrdquo

1959

[1112]

TheB

uild

andBloo

dPressure

Stud

yTablesw

eightb

yheight

bysexand

body

fram

e

USandCa

nada-in

sured

(from

26lifeinsurance

companies)p

eople

1935ndash195420

self-repo

rted

Streetshoesa

ndindo

orclo

thes

RevisedMLIC1959

tables

Stan

dard

Tablesbasedon

associa

tion

with

mortality(

notm

orbidity)

distrib

utionof

weighttoheight

associationwith

minim

ummortality

(lowestd

eath

rate)O

besity20above

idealw

eight

ldquoDesira

blew

eightrdquo

1975

[21]

FogartyCenter

Con

ferenceo

nObesity

Rangeo

facceptablew

eight

SuggestedrangeB

MI

201ndash

250form

en187ndash

238forw

omen

Basedon

MLIC1959

Adjuste

dstr

eet

shoesa

ndindo

orclo

thes

Guidan

ceforb

odyw

eight

Rangeo

facceptable

weight

Journal of Obesity 5

Table3Con

tinued

Year[ref]

Author

Criterialowast

Popu

latio

nScreening

Develo

pment

Milesto

neoutcome

1979

[1314]

TheB

uild

andBloo

dPressure

Stud

ysecond

study

Tablesw

eightb

yheight

bysexand

body

fram

e

Insuredpeop

le1950ndash1972

10self-repo

rted

Streetshoesa

ndindo

orclo

thes

RevisedMLIC1983

tables

ldquoHeig

httowe

ight

tablesrdquo

1980

[18]

USDepartm

ento

fAgriculture

andUS

Departm

ento

fHealth

Edu

catio

nandWelfare

Adjuste

drangeo

facceptable

weighto

fage

andheight

specific

MLIC59

Adjuste

dstr

eet

shoesa

ndindo

orclo

thes

DietaryG

uidancefor

America

ns(1s

tedition)

Rangeo

facceptable

weight

from

ldquodesira

blerdquo

weighttables

1985

[2223]NationalInstituteo

fHealth

ldquoOverw

eightrdquoB

MIge

85th

percentileldquosevereo

verw

eightrdquo

BMIge

95th

percentileo

f20-year-oldto

29-year-oldmen

andwom

enldquoObesityrdquo

andldquosevere

obesity

rdquosam

efor

thes

umof

the

tricepsa

ndsubscapu

larskinfold

thickn

esses

NHANES

II1976ndash80

Men

andwom

en20ndash29yearso

ld

Criteria

matched

forrange

ofacceptableweight

notge

20of

desir

ableweight

form

idpo

into

fmedium-build

person

MLIC

83

Guidan

ceforb

odyw

eight

Overw

eight-o

besityBM

Ige278form

enge273forw

omen

SuggestedrangeB

MIfor

malesand

females

264ndash285(M

LIC59)2

72ndash269(MLIC

83)

Rangeo

facceptable

weight

1985

[24]

USDepartm

ento

fAgriculture

andUS

Departm

ento

fHealth

Edu

catio

nandWelfare

Overw

eighttranslatedto

BMIfor

mensim25-26andforw

omen

sim24-25

MLIC59

DietaryG

uidancefor

America

ns(2nd

edition)

Desira

blew

eight

1990

[25]

USDepartm

ento

fAgriculture

andUS

Departm

ento

fHealth

Edu

catio

nandWelfare

BMIge

25fora

ges19ndash

34andge27

fora

gesge

35years

Alladults(both

sexesc

ombined)

by2ageg

roup

s

DietaryG

uidancefor

America

ns(3rd

edition)translated

inBM

Ige25

for

ages

19ndash34andge27

fora

gesge

35years

Unhealthyw

eight

1995

[15]

2000

[26]

World

Health

Organization(W

HO)

Mortalitycurve

Internationald

ata

Mortalitycurves

forB

MIsele

ction

Internationa

lClassificationofWeig

htInternationa

lClassifi

catio

nofWeig

htbasedon

BMIlevel

1995

[27]

USDepartm

ento

fAgriculture

andUS

Departm

ento

fHealth

Edu

catio

nandWelfare

BMIge

25fora

llages

Alladults(bothsexes

combined)

fora

llages

Noshoesno

clothes

DietaryG

uidancefor

America

ns(4th

edition)

Health

yweig

ht

1998

[2]

NationalInstituteo

fHealth

(NIH

)and

NationalH

eartLun

gandBloo

dInstitute

(NHLB

I)

Relatio

nof

BMIand

riskof

morbidityandmortality

RCTandepidem

iological

studies

Clinica

lGuidelin

eson

the

Identifi

catio

nEvaluatio

nan

dTreatm

entofO

verw

eight

andObesity

inAd

ults

Assessm

enta

ndtre

atmentm

anagem

ent

ofoverwe

ighta

ndobesity

6 Journal of Obesity

Table3Con

tinued

Year[ref]

Author

Criterialowast

Popu

latio

nScreening

Develo

pment

Milesto

neoutcome

2010

[16]

USDepartm

ento

fAgriculture

andUS

Departm

ento

fHealth

Edu

catio

nandWelfare

WHOInternationalC

lassificatio

nof

Weightb

ased

onBM

Ilevelwas

adop

tedforU

Spo

pulatio

nUSA

Matches

with

WHOandNIH

andNHLB

Icriteria

DietaryG

uidancefor

America

ns(7th

edition)lowastlowast

BMIclassification

matcheswith

WHOand

NIH

andNHLB

I1998

lowastCr

iteria

fortablegeneratio

nlowastlowastNexteditio

nisexpected

in2015

ldquoNationalN

utritionMon

itorin

gandRe

lated

Research

Acto

f1990rdquomdashPu

blicLaw101ndash445Title

IIISectio

n301sta

tedthatarepo

rtentitledldquoD

ietaryGu

idelinesfor

America

nsrdquos

hallcontainnu

trition

alanddietary

inform

ationandguidelines

forthe

generalpub

licandldquoshallbe

prom

oted

byeach

Federalagencyin

carrying

outany

Federalfoo

dnu

trition

orh

ealth

programrdquo[28]

Journal of Obesity 7

numbers came to the criteria of defining ldquooverweightrdquo as BMIge278 kgm2 for men and BMI ge273 for women [22] Thesecriteria matched with 20 or more above the ldquodesirablerdquoweight in the MLIC 1983 tables (from midpoint of the rangefor a medium-build person) [22] These definitions becamewidely accepted as the standards [22] Nevertheless numbersfor ranges of acceptable ldquonormalrdquo BMI were different fromthose based on the version of standard tables for example forMLIC 1959 264 (men) and 285 (women) and forMLIC 1983272 (men) and 269 (women) [23] Moreover the recom-mended requirement differed from the guidelines set up byFogarty Center and the Royal College of Physicians [21 35]Such discrepancies in the guidance pointed out the technicalproblems of weight to height tables the discrepancies ofmeasurements (shoes clothes and approximately 20 self-reported data in MLIC 1959 and 10 in MLIC 1983) andpopulation selection [35] It brought up an urgent need tostandardize definition of overweight and obesity and thesearch for weight to height index of body weight started

In 1985 the Department of Health and Human Services(HHS) and the Department of Agriculture (USDA) issuedthe second edition of ldquoDietary Guidelines for Americansrdquo [24]That document used the ldquodesirablerdquo weight to height tablesfromMLIC 1959 and translated the numbers into overweightlevel of BMI for men sim25-26 and for women sim24-25 [24 34]In the 1990 third edition tables for men and women werecombined into one and presented by two age groups whereldquounhealthyrdquo weight was translated into BMI ge 25 for ages 19ndash34 and ge27 for ages ge35 years [25 34]

In 1990 the ldquoNational Nutrition Monitoring and RelatedResearch Act of 1990rdquo Public Law 101ndash445 Title IIISection 301 stated that a report entitled ldquoDietary Guidelinesfor Americansrdquo shall contain nutritional and dietary informa-tion and guidelines for the general public and be publishedat least every five years [28] Each such report ldquoshall bepromoted by each Federal agency in carrying out any Federalfood nutrition or health programrdquo [28] Basically the lawstated that the definition of healthy weight or overweightfrom the Dietary Guidelines for Americans should be usedby the constituent Federal agencies [28]

In Geneva in 1995 WHO Expert Committee on PhysicalStatus published technical reportThe Use and Interpretationof Anthropometry [15] It was acknowledged that the basicanthropometry measurements of human body are weightand height [15] It was recommended to combine twobasic measurements weight and height into the body massindex (weightheight2) or ponderal index (weightheight3)for adults and three anthropometric indexes with consider-ation of age were described for children weight for heightheight for age and weight for age [15] The WHO ExpertCommittee on Physical Status proposed to classify differentlevels of BMI with cut-off points of 25 30 and 40 based onldquoarbitrarymethod of association betweenBMI andmortalityrdquo[15] WHO Expert Committee on Physical Status refer-enced the meta-analysis performed by Troiano et al whichincluded 17 studies with 37 substudies with 350000 menand gt38000 deaths plus six studies with 12 substudies with250000 women and 13700 deaths and presented the U-shapemortality rates that sharply increased when BMI lt185 and

Table 4 International classification of adults based on body massindex

Classification BMI (kgm2)Cut-off points Additional cut-off points

Underweight lt1850 lt185Severe thinness lt1600 lt160Moderate thinness 1600ndash1699 1600ndash1699Mild thinness 1700ndash1849 1700ndash1849

Normal 1850ndash2499 1850ndash22992300ndash2499

Overweight ge2500 ge2500

Preobese 2500ndash2999 2500ndash27492750ndash2999

Obese ge3000 ge3000

Class I 3000ndash3499 3000ndash32493250ndash3499

Class II 3500ndash3999 3500ndash37493750ndash3999

Class III ge4000 ge4000Source fromWHO 1995 WHO 2000 and WHO 2004 [15 26 29 30]

gt300 kgm2 with the acceptable BMI range as 185ndash2500 [15page 322] The WHO experts underscored that the cut-offswere chosen arbitrarily based on the ldquovisual inspection ofthe relationship between BMI and mortalityrdquo [15] curve forexample ldquothe cut-off of 30 is based on the point of flexionof the curverdquo [15] The authors suggested that this methodshould be revised in the future in terms of BMI associationwith health risk [15]

In 1995 the next step was taken to combine not justboth sexes but also age groups where ldquohealthyrdquo weight wastranslated in BMI ge25 for all adults in the fourth editionof ldquoDietary Guidelines for Americansrdquo [27] The report usedWHO criteria for publishing healthy weight ranges for menand women by each inch of height [27] The edition was veryimportant because it led to publishing the prevalence andtrends on overweight (BMI ge 25) preobese (BMI 250ndash299)class 1 (BMI 300ndash349) class 2 (BMI 350ndash399) and class3 (BMI ge 400) obese in the United States data from 1960to 1994 (NHANES I II and III) for first time to facilitatecomparison with international data [2]

Clinical Guidelines on the Identification Evaluation andTreatment of Overweight and Obesity in Adults (NIH Septem-ber 1998) defined overweight as a body mass index (BMI) of25 to 299 kgm2 and obesity as a BMI of ge30 kgm2 [2] Thepanel of experts came to this classification based on evidencefrom approximately 394 randomized controlled trials (RCTs)and multiple observational studies about BMI and risk ofmorbidity and mortality [2] The classification matched withone suggested by WHO [2 15]

In 2000 World Health Organization (WHO) definedoverweight and obesity as ldquothe disease in which excess bodyfat has accumulated to such an extent that health may beadversely affectedrdquo [26] and underscored that the practicaldefinition of obesity is based on the level of body massindex (BMI) [15 26]Themost recent version of international

8 Journal of Obesity

Table 5 Overweight and obese children and adolescents [16]

Category Children and adolescents (BMI for agepercentile rangelowast) Adults (BMI)

Underweight Less than the 5th percentile Less than 185 kgm2

Healthy weight 5th percentile to less than the 85th percentile 185 to 249 kgm2

Overweight 85th percentile to less than the 95th percentile 250 to 299 kgm2

Obese Equal to or greater than the 95th percentile 300 kgm2 or greaterlowastGrowth charts are available at httpwwwcdcgovgrowthcharts

classification for adults developed by WHO is presented inTable 4 [15 26]

BMI has never been a perfect index for children becauseit correlates with height In the United States Centers forDisease Control and Prevention (CDC) 2000 used fivenationally representative surveys to develop BMI charts forchildren in the United States the National Health Examina-tion Surveys (NHES) II and III in the 1960s the NationalHealth and Nutrition Examination Surveys (NHANES) I andII in the 1970s and NHANES III for the period of 1988ndash1994 Those charts included gender-specific BMI by singlemonth of age curves of growth Currently they are used inthe United States for children who are 2ndash19 years old todefine ldquooverweightrdquo as BMI ge95th percentile or ldquoat risk foroverweightrdquo if BMI is between 85th and 95th percentiles[26 36]

International surveys of six large and nationally repre-sentative cross-sectional growth studies from Brazil GreatBritain Hong Kong Netherlands Singapore and the UnitedStates were used by International Obesity Task Force (IOTF)to establish the cut-off points for overweight and obeseamong children and adolescents [37] In summary partic-ipants of IOTF agreed to link childhood overweight andobesity to the cut-offs for adults Based on each of the surveyspercentile curves were drawn in such a way that they passedthrough BMI cut-off points of 25 and 30 kgm2 at age of18 years and the resulting curves were averaged by age andgender to provide cut-off points for 2 through 18 years of age[37] This way less arbitrary and more internationally basedcut-offs were proposed [37]

In the current edition ofDietaryGuidelines for Americans2010 the BMI cut-offs are consistent with internationallyrecommended [16] By the Public Law 101ndash445 Title IIISection 301 all Federal agencies have made the transitionto define overweight and obesity as a BMI consistent withrecommendations in the current edition ofDietaryGuidelinesfor Americans [16 28] The table of weight category basedon BMI level from Dietary Guidelines for Americans 2010 ispresented in Table 5 [16]

4 Summary

There is nationwide and global epidemic of obesity As thefirst step to conquer a problem the concept of obesity shouldbe clearly understood through the historical process that ledto the worldwide accepted standard definition This paperpresents the history of developing current standard definitionof overweight and obesity Understanding the roots will lead

to the successful research on obesity with a goal to defeatnational and global epidemic

Competing Interests

The author declares that there are no competing interests

Acknowledgments

The author thanks Drs Michael Szarek Michael Walsh andElizabeth Helzner for assistance with development of thisproposal

References

[1] US Department of Health and Human Services The SurgeonGeneralrsquos Call to Action to Prevent and Decrease Overweight andObesity US Department ofHealth andHuman Services PublicHealth Service Office of the Surgeon General Rockville MdUSA 2001

[2] National Institutes of Health ldquoClinical guidelines on the identi-fication evaluation and treatment of overweight and obesity inadults-the evidence reportrdquoObesity Research vol 6 supplement2 pp 51Sndash209S 1998

[3] ldquoNutrition and overweightrdquo in Healthy People 2010 chapter 19pp 1ndash15 Food and Drug Administration National Institutes ofHealth Hyattsville Md USA 2001 httpwwwcdcgovnchsdatahpdata2010hp2010 final review focus area 19pdf

[4] H Christopoulou-Aletra andN Papavramidou ldquoMethods usedby the Hippocratic physicians for weight reductionrdquo WorldJournal of Surgery vol 28 no 5 pp 513ndash517 2004

[5] D Haslam ldquoObesity a medical historyrdquoObesity Reviews vol 8supplement 1 pp 31ndash36 2007

[6] H Schwartz Never Satisfied A Cultural History of DietsFantasies and Fat The Free Press New York NY USA 1986

[7] Medico-Actuarial Mortality Investigation vol 1 Association ofLife Insurance Medical Directors The Actuarial Society ofAmerica New York NY USA 1912

[8] L IDublin andA J LothaTwenty-Five Years ofHealth ProgressA Study of the Mortality Experience among the IndustrialPolicyholders of the Metropolitan Life Insurance Company 1911to 1935 Metropolitan Life Insurance New York NY USA 1937

[9] Ideal weight for women Statistical bulletin of the MetropolitanLife Insurance Company 1943

[10] Metropolitan Life Insurance Company ldquoIdeal weights for menrdquoStatistical Bulletin of the Metropolitan Life Insurance Companyvol 23 pp 6ndash8 1942

Journal of Obesity 9

[11] Metropolitan Life Insurance Company ldquoNew weight standardsfor men and womenrdquo Statistical Bulletin-Metropolitan LifeInsurance Company vol 40 pp 1ndash4 1959

[12] Build and Blood Pressure Study vol 1 Society of ActuariesChicago Ill USA 1959

[13] Metropolitan Life Insurance Company ldquoMetropolitan heightand weight tablesrdquo Statistical Bulletin (Metropolitan Life Insur-ance Company) vol 64 pp 1ndash19 1983

[14] Build Study 1979 Society of Actuaries and Associations of LifeInsurance Medical Directors Chicago Ill USA 1980

[15] WHO ldquoPhysical status the use and interpretation of anthro-pometryrdquo Report of a WHO Expert Committee WHO Tech-nical Report Series 854 World Health Organization GenevaSwitzerland 1995

[16] US Department of Agriculture and US Department of Healthand Human Services Dietary Guidelines for Americans 2010US Government Printing Office Washington DC USA 2010

[17] H C Fish The Agentrsquos Manual of Life Assurance Mutual LifeInsurance Company of New York New York NY USA 1867

[18] US Department of Agriculture and US Department of Healthand Human Services Nutrition and Your Health DietaryGuidelines for Americans US Government Printing OfficeWashington DC USA 1980

[19] M A Quetelet A Treatise on Man and the Development of HisFaculties William and Robert Chambers Edinburgh UK 1842

[20] J Hutchinson ldquoOn the capacity of the lungs and on therespiratory functions with a view of establishing a precise andeasy method of detecting disease by the spirometerrdquo Medico-Chirurgical Transactions (London) vol 29 pp 137ndash161 1846

[21] ldquoObesity in perspectiverdquo in Fogarty International Center Serieson PreventiveMedicine G Bray Ed vol 2 ofDHEWPublicationno (NIH) 75-708 part 1 1975 httpssearchworksstanfordeduview2520869

[22] ldquoHealth implications of obesity National Institutes of Healthconsensus development conference statementrdquo Annals of Inter-nal Medicine vol 103 no 1 pp 147ndash151 1985

[23] ldquoHealth implications of obesity National institutes of healthconsensus development conference statementrdquo Annals of Inter-nal Medicine vol 103 no 6 part 2 pp 1073ndash1077 1985

[24] US Department of Agriculture and US Department of Healthand Human Services Nutrition and Your Health DietaryGuidelines for Americans Home and Garden Bulletin no 232US Government Printing Office Washington DC USA 1985

[25] US Department of Agriculture and US Department of HealthandHuman ServicesNutrition and YourHealth Dietary Guide-lines for Americans vol 232 of Home and Garden Bulletin USGovernment Printing Office Washington DC USA 1990

[26] WHO ldquoObesity preventing and managing the global epi-demicrdquo WHO Technical Report Series 894 World HealthOrganization Geneva Switzerland 2000

[27] US Department of Agriculture and US Department of Healthand Human Services Nutrition and Your Health DietaryGuidelines for Americans US Government Printing OfficeWashington DC USA 1995

[28] Congressional Record Public law 101ndash445 National NutritionMonitoring and Related Research Act of 1990 October 1990[Congressional Record vol 136 House Report no 101 (Com-mittee on Agriculture)] 1990

[29] WHOIASOIOTF The Asia-Pacific Perspective RedefiningObesity and Its Treatment Health Communications Mel-bourne Australia 2000

[30] WHO Expert Consultation ldquoAppropriate body-mass index forAsian populations and its implications for policy and interven-tion strategiesrdquoTheLancet vol 363 no 9403 pp 157ndash163 2004

[31] J Yudkin ldquoObesity a report of the royal college of physiciansrdquoJournal of the Royal Society of Medicine vol 76 no 6 pp 531ndash532 1983

[32] The Secretary of Health and Human Services Charter 2015Dietary Guidelines Advisory CommitteeThe Secretary ofHealthand Human Services Washington DC USA 2015

[33] W F Kemsley W Z Billewicz and A M Thomson ldquoA newweight-for-height standard based on British Anthropometricdatardquo British Journal of Preventive amp Social Medicine vol 16 pp189ndash195 1962

[34] R J Kuczmarski and K M Flegal ldquoCriteria for definition ofoverweight in transition background and recommendations forthe United Statesrdquo The American Journal of Clinical Nutritionvol 72 no 5 pp 1074ndash1081 2000

[35] R J Jarrett ldquoIs there an ideal body weightrdquo British MedicalJournal vol 293 no 6545 pp 493ndash495 1986

[36] K M Flegal C J Tabak and C L Ogden ldquoOverweightin children Definitions and interpretationrdquo Health EducationResearch vol 21 no 6 pp 755ndash760 2006

[37] T J Cole M C Bellizzi K M Flegal and W H DietzldquoEstablishing a standard definition for child overweight andobesity worldwide international surveyrdquo The British MedicalJournal vol 320 no 7244 pp 1240ndash1243 2000

Submit your manuscripts athttpwwwhindawicom

Stem CellsInternational

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

MEDIATORSINFLAMMATION

of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Behavioural Neurology

EndocrinologyInternational Journal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Disease Markers

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

BioMed Research International

OncologyJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Oxidative Medicine and Cellular Longevity

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

PPAR Research

The Scientific World JournalHindawi Publishing Corporation httpwwwhindawicom Volume 2014

Immunology ResearchHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Journal of

ObesityJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Computational and Mathematical Methods in Medicine

OphthalmologyJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Diabetes ResearchJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Research and TreatmentAIDS

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Gastroenterology Research and Practice

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Parkinsonrsquos Disease

Evidence-Based Complementary and Alternative Medicine

Volume 2014Hindawi Publishing Corporationhttpwwwhindawicom

4 Journal of Obesity

Table3Develop

mento

fweightstand

ardtables

Year[ref]

Author

Criterialowast

Popu

latio

nScreening

Develo

pment

Milesto

neoutcome

1842

[19]

Quetelet

Tablesw

eighttoheight

byage

grou

p203040

50and60

Belgianmen

andwom

enWith

clothes

and

shoes(as

is)

Develo

pedatableo

fthe

averagew

eight

byagesfora

sampleo

fBelg

ianmen

andwo

men

ldquoAverage

weightrdquo

Belgian

1846

[20]

Hutchinson

Tablesw

eighttoheight

for3

0yo

En

glish

men

from

51015840110158401015840

to6feet

5feet1inchto

6feet30y

o

2650En

glish

men

Averagew

eightsof

30yo

men

for

each

inch

ofheight

from

51015840110158401015840

to6feet

ldquoAverage

weightrdquo

English

1867

[17]

Fish

Tablesw

eighttoheight

for3

0yo

American

men

from

51015840110158401015840

to6feet

American

MedicalRe

view

ofEn

glish

Tables

(from

John

Hutchinson)

TheA

gentrsquosManua

lofL

ifeAssurance

ldquoAverage

weightrdquo

American

1912

[7]

TheA

ssociatio

nof

LifeInsurance

MedicalDire

ctors

andtheA

ctuaria

lSo

cietyof

America

Tablesbased

onrateofmortality

weightb

yheight

tables

form

enandwom

enby

age

Mortalityforinsured

popu

latio

n

Season

alconsiderationto

have

thes

ame

clothes

andshoes

ReportofTh

eJoint

Committee

onTh

eMedico

-Actua

rial

MortalityInvestigationldquoA

verage

weightm

ayno

thavethe

lowest

mortalityrdquomdashwhatisidealweight

ldquoIdealweightrdquobasedon

longevity

1937

[8]

Dub

linandLo

tha

(1882ndash1969)

Metropo

litan

Life

InsuranceC

ompany

fram

e[8]1937

Tablesw

eighttoheight

bysexand

body

frame

sim4millionpeop

leinsured

byMetLife1911ndash

1935

Heightwith

street

shoesW

eighton

lyindo

orclo

thes

Dub

lindividedthea

verage

weights

into

threetypes

ofbo

dyfram

essmall

mediumand

largeF

rom

the

prospectiveo

finsurancethe

bad

weightw

asconsidered

tobe

20ndash25

with

morbidob

esity

at70ndash100above

theldquo

idealrdquo

ldquoIdealweightrdquo

(based

onlowest

mortalityforinsured

popu

latio

n)

1942-3

[910]

Metropo

litan

Life

InsuranceC

ompany

(MLIC)

Tablesw

eightb

yheight

bysexand

body

fram

eLo

ngevity

criteria

weight

maintainedatthes

amelevelas

25yo

with

sameh

eightand

body

fram

e

Prop

osed

tables

forldquoideal

weightrdquoform

enand

wom

engt25

yobyfram

esiz

e

Heightwith

street

shoes

Weighton

lyindo

orclo

thes

Natio

nalStand

ards

forW

eight

bysexandbody

frameM

LIC1942-43

Obesity20aboveidealweight

ldquoIdealweightrdquo

1959

[1112]

TheB

uild

andBloo

dPressure

Stud

yTablesw

eightb

yheight

bysexand

body

fram

e

USandCa

nada-in

sured

(from

26lifeinsurance

companies)p

eople

1935ndash195420

self-repo

rted

Streetshoesa

ndindo

orclo

thes

RevisedMLIC1959

tables

Stan

dard

Tablesbasedon

associa

tion

with

mortality(

notm

orbidity)

distrib

utionof

weighttoheight

associationwith

minim

ummortality

(lowestd

eath

rate)O

besity20above

idealw

eight

ldquoDesira

blew

eightrdquo

1975

[21]

FogartyCenter

Con

ferenceo

nObesity

Rangeo

facceptablew

eight

SuggestedrangeB

MI

201ndash

250form

en187ndash

238forw

omen

Basedon

MLIC1959

Adjuste

dstr

eet

shoesa

ndindo

orclo

thes

Guidan

ceforb

odyw

eight

Rangeo

facceptable

weight

Journal of Obesity 5

Table3Con

tinued

Year[ref]

Author

Criterialowast

Popu

latio

nScreening

Develo

pment

Milesto

neoutcome

1979

[1314]

TheB

uild

andBloo

dPressure

Stud

ysecond

study

Tablesw

eightb

yheight

bysexand

body

fram

e

Insuredpeop

le1950ndash1972

10self-repo

rted

Streetshoesa

ndindo

orclo

thes

RevisedMLIC1983

tables

ldquoHeig

httowe

ight

tablesrdquo

1980

[18]

USDepartm

ento

fAgriculture

andUS

Departm

ento

fHealth

Edu

catio

nandWelfare

Adjuste

drangeo

facceptable

weighto

fage

andheight

specific

MLIC59

Adjuste

dstr

eet

shoesa

ndindo

orclo

thes

DietaryG

uidancefor

America

ns(1s

tedition)

Rangeo

facceptable

weight

from

ldquodesira

blerdquo

weighttables

1985

[2223]NationalInstituteo

fHealth

ldquoOverw

eightrdquoB

MIge

85th

percentileldquosevereo

verw

eightrdquo

BMIge

95th

percentileo

f20-year-oldto

29-year-oldmen

andwom

enldquoObesityrdquo

andldquosevere

obesity

rdquosam

efor

thes

umof

the

tricepsa

ndsubscapu

larskinfold

thickn

esses

NHANES

II1976ndash80

Men

andwom

en20ndash29yearso

ld

Criteria

matched

forrange

ofacceptableweight

notge

20of

desir

ableweight

form

idpo

into

fmedium-build

person

MLIC

83

Guidan

ceforb

odyw

eight

Overw

eight-o

besityBM

Ige278form

enge273forw

omen

SuggestedrangeB

MIfor

malesand

females

264ndash285(M

LIC59)2

72ndash269(MLIC

83)

Rangeo

facceptable

weight

1985

[24]

USDepartm

ento

fAgriculture

andUS

Departm

ento

fHealth

Edu

catio

nandWelfare

Overw

eighttranslatedto

BMIfor

mensim25-26andforw

omen

sim24-25

MLIC59

DietaryG

uidancefor

America

ns(2nd

edition)

Desira

blew

eight

1990

[25]

USDepartm

ento

fAgriculture

andUS

Departm

ento

fHealth

Edu

catio

nandWelfare

BMIge

25fora

ges19ndash

34andge27

fora

gesge

35years

Alladults(both

sexesc

ombined)

by2ageg

roup

s

DietaryG

uidancefor

America

ns(3rd

edition)translated

inBM

Ige25

for

ages

19ndash34andge27

fora

gesge

35years

Unhealthyw

eight

1995

[15]

2000

[26]

World

Health

Organization(W

HO)

Mortalitycurve

Internationald

ata

Mortalitycurves

forB

MIsele

ction

Internationa

lClassificationofWeig

htInternationa

lClassifi

catio

nofWeig

htbasedon

BMIlevel

1995

[27]

USDepartm

ento

fAgriculture

andUS

Departm

ento

fHealth

Edu

catio

nandWelfare

BMIge

25fora

llages

Alladults(bothsexes

combined)

fora

llages

Noshoesno

clothes

DietaryG

uidancefor

America

ns(4th

edition)

Health

yweig

ht

1998

[2]

NationalInstituteo

fHealth

(NIH

)and

NationalH

eartLun

gandBloo

dInstitute

(NHLB

I)

Relatio

nof

BMIand

riskof

morbidityandmortality

RCTandepidem

iological

studies

Clinica

lGuidelin

eson

the

Identifi

catio

nEvaluatio

nan

dTreatm

entofO

verw

eight

andObesity

inAd

ults

Assessm

enta

ndtre

atmentm

anagem

ent

ofoverwe

ighta

ndobesity

6 Journal of Obesity

Table3Con

tinued

Year[ref]

Author

Criterialowast

Popu

latio

nScreening

Develo

pment

Milesto

neoutcome

2010

[16]

USDepartm

ento

fAgriculture

andUS

Departm

ento

fHealth

Edu

catio

nandWelfare

WHOInternationalC

lassificatio

nof

Weightb

ased

onBM

Ilevelwas

adop

tedforU

Spo

pulatio

nUSA

Matches

with

WHOandNIH

andNHLB

Icriteria

DietaryG

uidancefor

America

ns(7th

edition)lowastlowast

BMIclassification

matcheswith

WHOand

NIH

andNHLB

I1998

lowastCr

iteria

fortablegeneratio

nlowastlowastNexteditio

nisexpected

in2015

ldquoNationalN

utritionMon

itorin

gandRe

lated

Research

Acto

f1990rdquomdashPu

blicLaw101ndash445Title

IIISectio

n301sta

tedthatarepo

rtentitledldquoD

ietaryGu

idelinesfor

America

nsrdquos

hallcontainnu

trition

alanddietary

inform

ationandguidelines

forthe

generalpub

licandldquoshallbe

prom

oted

byeach

Federalagencyin

carrying

outany

Federalfoo

dnu

trition

orh

ealth

programrdquo[28]

Journal of Obesity 7

numbers came to the criteria of defining ldquooverweightrdquo as BMIge278 kgm2 for men and BMI ge273 for women [22] Thesecriteria matched with 20 or more above the ldquodesirablerdquoweight in the MLIC 1983 tables (from midpoint of the rangefor a medium-build person) [22] These definitions becamewidely accepted as the standards [22] Nevertheless numbersfor ranges of acceptable ldquonormalrdquo BMI were different fromthose based on the version of standard tables for example forMLIC 1959 264 (men) and 285 (women) and forMLIC 1983272 (men) and 269 (women) [23] Moreover the recom-mended requirement differed from the guidelines set up byFogarty Center and the Royal College of Physicians [21 35]Such discrepancies in the guidance pointed out the technicalproblems of weight to height tables the discrepancies ofmeasurements (shoes clothes and approximately 20 self-reported data in MLIC 1959 and 10 in MLIC 1983) andpopulation selection [35] It brought up an urgent need tostandardize definition of overweight and obesity and thesearch for weight to height index of body weight started

In 1985 the Department of Health and Human Services(HHS) and the Department of Agriculture (USDA) issuedthe second edition of ldquoDietary Guidelines for Americansrdquo [24]That document used the ldquodesirablerdquo weight to height tablesfromMLIC 1959 and translated the numbers into overweightlevel of BMI for men sim25-26 and for women sim24-25 [24 34]In the 1990 third edition tables for men and women werecombined into one and presented by two age groups whereldquounhealthyrdquo weight was translated into BMI ge 25 for ages 19ndash34 and ge27 for ages ge35 years [25 34]

In 1990 the ldquoNational Nutrition Monitoring and RelatedResearch Act of 1990rdquo Public Law 101ndash445 Title IIISection 301 stated that a report entitled ldquoDietary Guidelinesfor Americansrdquo shall contain nutritional and dietary informa-tion and guidelines for the general public and be publishedat least every five years [28] Each such report ldquoshall bepromoted by each Federal agency in carrying out any Federalfood nutrition or health programrdquo [28] Basically the lawstated that the definition of healthy weight or overweightfrom the Dietary Guidelines for Americans should be usedby the constituent Federal agencies [28]

In Geneva in 1995 WHO Expert Committee on PhysicalStatus published technical reportThe Use and Interpretationof Anthropometry [15] It was acknowledged that the basicanthropometry measurements of human body are weightand height [15] It was recommended to combine twobasic measurements weight and height into the body massindex (weightheight2) or ponderal index (weightheight3)for adults and three anthropometric indexes with consider-ation of age were described for children weight for heightheight for age and weight for age [15] The WHO ExpertCommittee on Physical Status proposed to classify differentlevels of BMI with cut-off points of 25 30 and 40 based onldquoarbitrarymethod of association betweenBMI andmortalityrdquo[15] WHO Expert Committee on Physical Status refer-enced the meta-analysis performed by Troiano et al whichincluded 17 studies with 37 substudies with 350000 menand gt38000 deaths plus six studies with 12 substudies with250000 women and 13700 deaths and presented the U-shapemortality rates that sharply increased when BMI lt185 and

Table 4 International classification of adults based on body massindex

Classification BMI (kgm2)Cut-off points Additional cut-off points

Underweight lt1850 lt185Severe thinness lt1600 lt160Moderate thinness 1600ndash1699 1600ndash1699Mild thinness 1700ndash1849 1700ndash1849

Normal 1850ndash2499 1850ndash22992300ndash2499

Overweight ge2500 ge2500

Preobese 2500ndash2999 2500ndash27492750ndash2999

Obese ge3000 ge3000

Class I 3000ndash3499 3000ndash32493250ndash3499

Class II 3500ndash3999 3500ndash37493750ndash3999

Class III ge4000 ge4000Source fromWHO 1995 WHO 2000 and WHO 2004 [15 26 29 30]

gt300 kgm2 with the acceptable BMI range as 185ndash2500 [15page 322] The WHO experts underscored that the cut-offswere chosen arbitrarily based on the ldquovisual inspection ofthe relationship between BMI and mortalityrdquo [15] curve forexample ldquothe cut-off of 30 is based on the point of flexionof the curverdquo [15] The authors suggested that this methodshould be revised in the future in terms of BMI associationwith health risk [15]

In 1995 the next step was taken to combine not justboth sexes but also age groups where ldquohealthyrdquo weight wastranslated in BMI ge25 for all adults in the fourth editionof ldquoDietary Guidelines for Americansrdquo [27] The report usedWHO criteria for publishing healthy weight ranges for menand women by each inch of height [27] The edition was veryimportant because it led to publishing the prevalence andtrends on overweight (BMI ge 25) preobese (BMI 250ndash299)class 1 (BMI 300ndash349) class 2 (BMI 350ndash399) and class3 (BMI ge 400) obese in the United States data from 1960to 1994 (NHANES I II and III) for first time to facilitatecomparison with international data [2]

Clinical Guidelines on the Identification Evaluation andTreatment of Overweight and Obesity in Adults (NIH Septem-ber 1998) defined overweight as a body mass index (BMI) of25 to 299 kgm2 and obesity as a BMI of ge30 kgm2 [2] Thepanel of experts came to this classification based on evidencefrom approximately 394 randomized controlled trials (RCTs)and multiple observational studies about BMI and risk ofmorbidity and mortality [2] The classification matched withone suggested by WHO [2 15]

In 2000 World Health Organization (WHO) definedoverweight and obesity as ldquothe disease in which excess bodyfat has accumulated to such an extent that health may beadversely affectedrdquo [26] and underscored that the practicaldefinition of obesity is based on the level of body massindex (BMI) [15 26]Themost recent version of international

8 Journal of Obesity

Table 5 Overweight and obese children and adolescents [16]

Category Children and adolescents (BMI for agepercentile rangelowast) Adults (BMI)

Underweight Less than the 5th percentile Less than 185 kgm2

Healthy weight 5th percentile to less than the 85th percentile 185 to 249 kgm2

Overweight 85th percentile to less than the 95th percentile 250 to 299 kgm2

Obese Equal to or greater than the 95th percentile 300 kgm2 or greaterlowastGrowth charts are available at httpwwwcdcgovgrowthcharts

classification for adults developed by WHO is presented inTable 4 [15 26]

BMI has never been a perfect index for children becauseit correlates with height In the United States Centers forDisease Control and Prevention (CDC) 2000 used fivenationally representative surveys to develop BMI charts forchildren in the United States the National Health Examina-tion Surveys (NHES) II and III in the 1960s the NationalHealth and Nutrition Examination Surveys (NHANES) I andII in the 1970s and NHANES III for the period of 1988ndash1994 Those charts included gender-specific BMI by singlemonth of age curves of growth Currently they are used inthe United States for children who are 2ndash19 years old todefine ldquooverweightrdquo as BMI ge95th percentile or ldquoat risk foroverweightrdquo if BMI is between 85th and 95th percentiles[26 36]

International surveys of six large and nationally repre-sentative cross-sectional growth studies from Brazil GreatBritain Hong Kong Netherlands Singapore and the UnitedStates were used by International Obesity Task Force (IOTF)to establish the cut-off points for overweight and obeseamong children and adolescents [37] In summary partic-ipants of IOTF agreed to link childhood overweight andobesity to the cut-offs for adults Based on each of the surveyspercentile curves were drawn in such a way that they passedthrough BMI cut-off points of 25 and 30 kgm2 at age of18 years and the resulting curves were averaged by age andgender to provide cut-off points for 2 through 18 years of age[37] This way less arbitrary and more internationally basedcut-offs were proposed [37]

In the current edition ofDietaryGuidelines for Americans2010 the BMI cut-offs are consistent with internationallyrecommended [16] By the Public Law 101ndash445 Title IIISection 301 all Federal agencies have made the transitionto define overweight and obesity as a BMI consistent withrecommendations in the current edition ofDietaryGuidelinesfor Americans [16 28] The table of weight category basedon BMI level from Dietary Guidelines for Americans 2010 ispresented in Table 5 [16]

4 Summary

There is nationwide and global epidemic of obesity As thefirst step to conquer a problem the concept of obesity shouldbe clearly understood through the historical process that ledto the worldwide accepted standard definition This paperpresents the history of developing current standard definitionof overweight and obesity Understanding the roots will lead

to the successful research on obesity with a goal to defeatnational and global epidemic

Competing Interests

The author declares that there are no competing interests

Acknowledgments

The author thanks Drs Michael Szarek Michael Walsh andElizabeth Helzner for assistance with development of thisproposal

References

[1] US Department of Health and Human Services The SurgeonGeneralrsquos Call to Action to Prevent and Decrease Overweight andObesity US Department ofHealth andHuman Services PublicHealth Service Office of the Surgeon General Rockville MdUSA 2001

[2] National Institutes of Health ldquoClinical guidelines on the identi-fication evaluation and treatment of overweight and obesity inadults-the evidence reportrdquoObesity Research vol 6 supplement2 pp 51Sndash209S 1998

[3] ldquoNutrition and overweightrdquo in Healthy People 2010 chapter 19pp 1ndash15 Food and Drug Administration National Institutes ofHealth Hyattsville Md USA 2001 httpwwwcdcgovnchsdatahpdata2010hp2010 final review focus area 19pdf

[4] H Christopoulou-Aletra andN Papavramidou ldquoMethods usedby the Hippocratic physicians for weight reductionrdquo WorldJournal of Surgery vol 28 no 5 pp 513ndash517 2004

[5] D Haslam ldquoObesity a medical historyrdquoObesity Reviews vol 8supplement 1 pp 31ndash36 2007

[6] H Schwartz Never Satisfied A Cultural History of DietsFantasies and Fat The Free Press New York NY USA 1986

[7] Medico-Actuarial Mortality Investigation vol 1 Association ofLife Insurance Medical Directors The Actuarial Society ofAmerica New York NY USA 1912

[8] L IDublin andA J LothaTwenty-Five Years ofHealth ProgressA Study of the Mortality Experience among the IndustrialPolicyholders of the Metropolitan Life Insurance Company 1911to 1935 Metropolitan Life Insurance New York NY USA 1937

[9] Ideal weight for women Statistical bulletin of the MetropolitanLife Insurance Company 1943

[10] Metropolitan Life Insurance Company ldquoIdeal weights for menrdquoStatistical Bulletin of the Metropolitan Life Insurance Companyvol 23 pp 6ndash8 1942

Journal of Obesity 9

[11] Metropolitan Life Insurance Company ldquoNew weight standardsfor men and womenrdquo Statistical Bulletin-Metropolitan LifeInsurance Company vol 40 pp 1ndash4 1959

[12] Build and Blood Pressure Study vol 1 Society of ActuariesChicago Ill USA 1959

[13] Metropolitan Life Insurance Company ldquoMetropolitan heightand weight tablesrdquo Statistical Bulletin (Metropolitan Life Insur-ance Company) vol 64 pp 1ndash19 1983

[14] Build Study 1979 Society of Actuaries and Associations of LifeInsurance Medical Directors Chicago Ill USA 1980

[15] WHO ldquoPhysical status the use and interpretation of anthro-pometryrdquo Report of a WHO Expert Committee WHO Tech-nical Report Series 854 World Health Organization GenevaSwitzerland 1995

[16] US Department of Agriculture and US Department of Healthand Human Services Dietary Guidelines for Americans 2010US Government Printing Office Washington DC USA 2010

[17] H C Fish The Agentrsquos Manual of Life Assurance Mutual LifeInsurance Company of New York New York NY USA 1867

[18] US Department of Agriculture and US Department of Healthand Human Services Nutrition and Your Health DietaryGuidelines for Americans US Government Printing OfficeWashington DC USA 1980

[19] M A Quetelet A Treatise on Man and the Development of HisFaculties William and Robert Chambers Edinburgh UK 1842

[20] J Hutchinson ldquoOn the capacity of the lungs and on therespiratory functions with a view of establishing a precise andeasy method of detecting disease by the spirometerrdquo Medico-Chirurgical Transactions (London) vol 29 pp 137ndash161 1846

[21] ldquoObesity in perspectiverdquo in Fogarty International Center Serieson PreventiveMedicine G Bray Ed vol 2 ofDHEWPublicationno (NIH) 75-708 part 1 1975 httpssearchworksstanfordeduview2520869

[22] ldquoHealth implications of obesity National Institutes of Healthconsensus development conference statementrdquo Annals of Inter-nal Medicine vol 103 no 1 pp 147ndash151 1985

[23] ldquoHealth implications of obesity National institutes of healthconsensus development conference statementrdquo Annals of Inter-nal Medicine vol 103 no 6 part 2 pp 1073ndash1077 1985

[24] US Department of Agriculture and US Department of Healthand Human Services Nutrition and Your Health DietaryGuidelines for Americans Home and Garden Bulletin no 232US Government Printing Office Washington DC USA 1985

[25] US Department of Agriculture and US Department of HealthandHuman ServicesNutrition and YourHealth Dietary Guide-lines for Americans vol 232 of Home and Garden Bulletin USGovernment Printing Office Washington DC USA 1990

[26] WHO ldquoObesity preventing and managing the global epi-demicrdquo WHO Technical Report Series 894 World HealthOrganization Geneva Switzerland 2000

[27] US Department of Agriculture and US Department of Healthand Human Services Nutrition and Your Health DietaryGuidelines for Americans US Government Printing OfficeWashington DC USA 1995

[28] Congressional Record Public law 101ndash445 National NutritionMonitoring and Related Research Act of 1990 October 1990[Congressional Record vol 136 House Report no 101 (Com-mittee on Agriculture)] 1990

[29] WHOIASOIOTF The Asia-Pacific Perspective RedefiningObesity and Its Treatment Health Communications Mel-bourne Australia 2000

[30] WHO Expert Consultation ldquoAppropriate body-mass index forAsian populations and its implications for policy and interven-tion strategiesrdquoTheLancet vol 363 no 9403 pp 157ndash163 2004

[31] J Yudkin ldquoObesity a report of the royal college of physiciansrdquoJournal of the Royal Society of Medicine vol 76 no 6 pp 531ndash532 1983

[32] The Secretary of Health and Human Services Charter 2015Dietary Guidelines Advisory CommitteeThe Secretary ofHealthand Human Services Washington DC USA 2015

[33] W F Kemsley W Z Billewicz and A M Thomson ldquoA newweight-for-height standard based on British Anthropometricdatardquo British Journal of Preventive amp Social Medicine vol 16 pp189ndash195 1962

[34] R J Kuczmarski and K M Flegal ldquoCriteria for definition ofoverweight in transition background and recommendations forthe United Statesrdquo The American Journal of Clinical Nutritionvol 72 no 5 pp 1074ndash1081 2000

[35] R J Jarrett ldquoIs there an ideal body weightrdquo British MedicalJournal vol 293 no 6545 pp 493ndash495 1986

[36] K M Flegal C J Tabak and C L Ogden ldquoOverweightin children Definitions and interpretationrdquo Health EducationResearch vol 21 no 6 pp 755ndash760 2006

[37] T J Cole M C Bellizzi K M Flegal and W H DietzldquoEstablishing a standard definition for child overweight andobesity worldwide international surveyrdquo The British MedicalJournal vol 320 no 7244 pp 1240ndash1243 2000

Submit your manuscripts athttpwwwhindawicom

Stem CellsInternational

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

MEDIATORSINFLAMMATION

of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Behavioural Neurology

EndocrinologyInternational Journal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Disease Markers

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

BioMed Research International

OncologyJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Oxidative Medicine and Cellular Longevity

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

PPAR Research

The Scientific World JournalHindawi Publishing Corporation httpwwwhindawicom Volume 2014

Immunology ResearchHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Journal of

ObesityJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Computational and Mathematical Methods in Medicine

OphthalmologyJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Diabetes ResearchJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Research and TreatmentAIDS

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Gastroenterology Research and Practice

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Parkinsonrsquos Disease

Evidence-Based Complementary and Alternative Medicine

Volume 2014Hindawi Publishing Corporationhttpwwwhindawicom

Journal of Obesity 5

Table3Con

tinued

Year[ref]

Author

Criterialowast

Popu

latio

nScreening

Develo

pment

Milesto

neoutcome

1979

[1314]

TheB

uild

andBloo

dPressure

Stud

ysecond

study

Tablesw

eightb

yheight

bysexand

body

fram

e

Insuredpeop

le1950ndash1972

10self-repo

rted

Streetshoesa

ndindo

orclo

thes

RevisedMLIC1983

tables

ldquoHeig

httowe

ight

tablesrdquo

1980

[18]

USDepartm

ento

fAgriculture

andUS

Departm

ento

fHealth

Edu

catio

nandWelfare

Adjuste

drangeo

facceptable

weighto

fage

andheight

specific

MLIC59

Adjuste

dstr

eet

shoesa

ndindo

orclo

thes

DietaryG

uidancefor

America

ns(1s

tedition)

Rangeo

facceptable

weight

from

ldquodesira

blerdquo

weighttables

1985

[2223]NationalInstituteo

fHealth

ldquoOverw

eightrdquoB

MIge

85th

percentileldquosevereo

verw

eightrdquo

BMIge

95th

percentileo

f20-year-oldto

29-year-oldmen

andwom

enldquoObesityrdquo

andldquosevere

obesity

rdquosam

efor

thes

umof

the

tricepsa

ndsubscapu

larskinfold

thickn

esses

NHANES

II1976ndash80

Men

andwom

en20ndash29yearso

ld

Criteria

matched

forrange

ofacceptableweight

notge

20of

desir

ableweight

form

idpo

into

fmedium-build

person

MLIC

83

Guidan

ceforb

odyw

eight

Overw

eight-o

besityBM

Ige278form

enge273forw

omen

SuggestedrangeB

MIfor

malesand

females

264ndash285(M

LIC59)2

72ndash269(MLIC

83)

Rangeo

facceptable

weight

1985

[24]

USDepartm

ento

fAgriculture

andUS

Departm

ento

fHealth

Edu

catio

nandWelfare

Overw

eighttranslatedto

BMIfor

mensim25-26andforw

omen

sim24-25

MLIC59

DietaryG

uidancefor

America

ns(2nd

edition)

Desira

blew

eight

1990

[25]

USDepartm

ento

fAgriculture

andUS

Departm

ento

fHealth

Edu

catio

nandWelfare

BMIge

25fora

ges19ndash

34andge27

fora

gesge

35years

Alladults(both

sexesc

ombined)

by2ageg

roup

s

DietaryG

uidancefor

America

ns(3rd

edition)translated

inBM

Ige25

for

ages

19ndash34andge27

fora

gesge

35years

Unhealthyw

eight

1995

[15]

2000

[26]

World

Health

Organization(W

HO)

Mortalitycurve

Internationald

ata

Mortalitycurves

forB

MIsele

ction

Internationa

lClassificationofWeig

htInternationa

lClassifi

catio

nofWeig

htbasedon

BMIlevel

1995

[27]

USDepartm

ento

fAgriculture

andUS

Departm

ento

fHealth

Edu

catio

nandWelfare

BMIge

25fora

llages

Alladults(bothsexes

combined)

fora

llages

Noshoesno

clothes

DietaryG

uidancefor

America

ns(4th

edition)

Health

yweig

ht

1998

[2]

NationalInstituteo

fHealth

(NIH

)and

NationalH

eartLun

gandBloo

dInstitute

(NHLB

I)

Relatio

nof

BMIand

riskof

morbidityandmortality

RCTandepidem

iological

studies

Clinica

lGuidelin

eson

the

Identifi

catio

nEvaluatio

nan

dTreatm

entofO

verw

eight

andObesity

inAd

ults

Assessm

enta

ndtre

atmentm

anagem

ent

ofoverwe

ighta

ndobesity

6 Journal of Obesity

Table3Con

tinued

Year[ref]

Author

Criterialowast

Popu

latio

nScreening

Develo

pment

Milesto

neoutcome

2010

[16]

USDepartm

ento

fAgriculture

andUS

Departm

ento

fHealth

Edu

catio

nandWelfare

WHOInternationalC

lassificatio

nof

Weightb

ased

onBM

Ilevelwas

adop

tedforU

Spo

pulatio

nUSA

Matches

with

WHOandNIH

andNHLB

Icriteria

DietaryG

uidancefor

America

ns(7th

edition)lowastlowast

BMIclassification

matcheswith

WHOand

NIH

andNHLB

I1998

lowastCr

iteria

fortablegeneratio

nlowastlowastNexteditio

nisexpected

in2015

ldquoNationalN

utritionMon

itorin

gandRe

lated

Research

Acto

f1990rdquomdashPu

blicLaw101ndash445Title

IIISectio

n301sta

tedthatarepo

rtentitledldquoD

ietaryGu

idelinesfor

America

nsrdquos

hallcontainnu

trition

alanddietary

inform

ationandguidelines

forthe

generalpub

licandldquoshallbe

prom

oted

byeach

Federalagencyin

carrying

outany

Federalfoo

dnu

trition

orh

ealth

programrdquo[28]

Journal of Obesity 7

numbers came to the criteria of defining ldquooverweightrdquo as BMIge278 kgm2 for men and BMI ge273 for women [22] Thesecriteria matched with 20 or more above the ldquodesirablerdquoweight in the MLIC 1983 tables (from midpoint of the rangefor a medium-build person) [22] These definitions becamewidely accepted as the standards [22] Nevertheless numbersfor ranges of acceptable ldquonormalrdquo BMI were different fromthose based on the version of standard tables for example forMLIC 1959 264 (men) and 285 (women) and forMLIC 1983272 (men) and 269 (women) [23] Moreover the recom-mended requirement differed from the guidelines set up byFogarty Center and the Royal College of Physicians [21 35]Such discrepancies in the guidance pointed out the technicalproblems of weight to height tables the discrepancies ofmeasurements (shoes clothes and approximately 20 self-reported data in MLIC 1959 and 10 in MLIC 1983) andpopulation selection [35] It brought up an urgent need tostandardize definition of overweight and obesity and thesearch for weight to height index of body weight started

In 1985 the Department of Health and Human Services(HHS) and the Department of Agriculture (USDA) issuedthe second edition of ldquoDietary Guidelines for Americansrdquo [24]That document used the ldquodesirablerdquo weight to height tablesfromMLIC 1959 and translated the numbers into overweightlevel of BMI for men sim25-26 and for women sim24-25 [24 34]In the 1990 third edition tables for men and women werecombined into one and presented by two age groups whereldquounhealthyrdquo weight was translated into BMI ge 25 for ages 19ndash34 and ge27 for ages ge35 years [25 34]

In 1990 the ldquoNational Nutrition Monitoring and RelatedResearch Act of 1990rdquo Public Law 101ndash445 Title IIISection 301 stated that a report entitled ldquoDietary Guidelinesfor Americansrdquo shall contain nutritional and dietary informa-tion and guidelines for the general public and be publishedat least every five years [28] Each such report ldquoshall bepromoted by each Federal agency in carrying out any Federalfood nutrition or health programrdquo [28] Basically the lawstated that the definition of healthy weight or overweightfrom the Dietary Guidelines for Americans should be usedby the constituent Federal agencies [28]

In Geneva in 1995 WHO Expert Committee on PhysicalStatus published technical reportThe Use and Interpretationof Anthropometry [15] It was acknowledged that the basicanthropometry measurements of human body are weightand height [15] It was recommended to combine twobasic measurements weight and height into the body massindex (weightheight2) or ponderal index (weightheight3)for adults and three anthropometric indexes with consider-ation of age were described for children weight for heightheight for age and weight for age [15] The WHO ExpertCommittee on Physical Status proposed to classify differentlevels of BMI with cut-off points of 25 30 and 40 based onldquoarbitrarymethod of association betweenBMI andmortalityrdquo[15] WHO Expert Committee on Physical Status refer-enced the meta-analysis performed by Troiano et al whichincluded 17 studies with 37 substudies with 350000 menand gt38000 deaths plus six studies with 12 substudies with250000 women and 13700 deaths and presented the U-shapemortality rates that sharply increased when BMI lt185 and

Table 4 International classification of adults based on body massindex

Classification BMI (kgm2)Cut-off points Additional cut-off points

Underweight lt1850 lt185Severe thinness lt1600 lt160Moderate thinness 1600ndash1699 1600ndash1699Mild thinness 1700ndash1849 1700ndash1849

Normal 1850ndash2499 1850ndash22992300ndash2499

Overweight ge2500 ge2500

Preobese 2500ndash2999 2500ndash27492750ndash2999

Obese ge3000 ge3000

Class I 3000ndash3499 3000ndash32493250ndash3499

Class II 3500ndash3999 3500ndash37493750ndash3999

Class III ge4000 ge4000Source fromWHO 1995 WHO 2000 and WHO 2004 [15 26 29 30]

gt300 kgm2 with the acceptable BMI range as 185ndash2500 [15page 322] The WHO experts underscored that the cut-offswere chosen arbitrarily based on the ldquovisual inspection ofthe relationship between BMI and mortalityrdquo [15] curve forexample ldquothe cut-off of 30 is based on the point of flexionof the curverdquo [15] The authors suggested that this methodshould be revised in the future in terms of BMI associationwith health risk [15]

In 1995 the next step was taken to combine not justboth sexes but also age groups where ldquohealthyrdquo weight wastranslated in BMI ge25 for all adults in the fourth editionof ldquoDietary Guidelines for Americansrdquo [27] The report usedWHO criteria for publishing healthy weight ranges for menand women by each inch of height [27] The edition was veryimportant because it led to publishing the prevalence andtrends on overweight (BMI ge 25) preobese (BMI 250ndash299)class 1 (BMI 300ndash349) class 2 (BMI 350ndash399) and class3 (BMI ge 400) obese in the United States data from 1960to 1994 (NHANES I II and III) for first time to facilitatecomparison with international data [2]

Clinical Guidelines on the Identification Evaluation andTreatment of Overweight and Obesity in Adults (NIH Septem-ber 1998) defined overweight as a body mass index (BMI) of25 to 299 kgm2 and obesity as a BMI of ge30 kgm2 [2] Thepanel of experts came to this classification based on evidencefrom approximately 394 randomized controlled trials (RCTs)and multiple observational studies about BMI and risk ofmorbidity and mortality [2] The classification matched withone suggested by WHO [2 15]

In 2000 World Health Organization (WHO) definedoverweight and obesity as ldquothe disease in which excess bodyfat has accumulated to such an extent that health may beadversely affectedrdquo [26] and underscored that the practicaldefinition of obesity is based on the level of body massindex (BMI) [15 26]Themost recent version of international

8 Journal of Obesity

Table 5 Overweight and obese children and adolescents [16]

Category Children and adolescents (BMI for agepercentile rangelowast) Adults (BMI)

Underweight Less than the 5th percentile Less than 185 kgm2

Healthy weight 5th percentile to less than the 85th percentile 185 to 249 kgm2

Overweight 85th percentile to less than the 95th percentile 250 to 299 kgm2

Obese Equal to or greater than the 95th percentile 300 kgm2 or greaterlowastGrowth charts are available at httpwwwcdcgovgrowthcharts

classification for adults developed by WHO is presented inTable 4 [15 26]

BMI has never been a perfect index for children becauseit correlates with height In the United States Centers forDisease Control and Prevention (CDC) 2000 used fivenationally representative surveys to develop BMI charts forchildren in the United States the National Health Examina-tion Surveys (NHES) II and III in the 1960s the NationalHealth and Nutrition Examination Surveys (NHANES) I andII in the 1970s and NHANES III for the period of 1988ndash1994 Those charts included gender-specific BMI by singlemonth of age curves of growth Currently they are used inthe United States for children who are 2ndash19 years old todefine ldquooverweightrdquo as BMI ge95th percentile or ldquoat risk foroverweightrdquo if BMI is between 85th and 95th percentiles[26 36]

International surveys of six large and nationally repre-sentative cross-sectional growth studies from Brazil GreatBritain Hong Kong Netherlands Singapore and the UnitedStates were used by International Obesity Task Force (IOTF)to establish the cut-off points for overweight and obeseamong children and adolescents [37] In summary partic-ipants of IOTF agreed to link childhood overweight andobesity to the cut-offs for adults Based on each of the surveyspercentile curves were drawn in such a way that they passedthrough BMI cut-off points of 25 and 30 kgm2 at age of18 years and the resulting curves were averaged by age andgender to provide cut-off points for 2 through 18 years of age[37] This way less arbitrary and more internationally basedcut-offs were proposed [37]

In the current edition ofDietaryGuidelines for Americans2010 the BMI cut-offs are consistent with internationallyrecommended [16] By the Public Law 101ndash445 Title IIISection 301 all Federal agencies have made the transitionto define overweight and obesity as a BMI consistent withrecommendations in the current edition ofDietaryGuidelinesfor Americans [16 28] The table of weight category basedon BMI level from Dietary Guidelines for Americans 2010 ispresented in Table 5 [16]

4 Summary

There is nationwide and global epidemic of obesity As thefirst step to conquer a problem the concept of obesity shouldbe clearly understood through the historical process that ledto the worldwide accepted standard definition This paperpresents the history of developing current standard definitionof overweight and obesity Understanding the roots will lead

to the successful research on obesity with a goal to defeatnational and global epidemic

Competing Interests

The author declares that there are no competing interests

Acknowledgments

The author thanks Drs Michael Szarek Michael Walsh andElizabeth Helzner for assistance with development of thisproposal

References

[1] US Department of Health and Human Services The SurgeonGeneralrsquos Call to Action to Prevent and Decrease Overweight andObesity US Department ofHealth andHuman Services PublicHealth Service Office of the Surgeon General Rockville MdUSA 2001

[2] National Institutes of Health ldquoClinical guidelines on the identi-fication evaluation and treatment of overweight and obesity inadults-the evidence reportrdquoObesity Research vol 6 supplement2 pp 51Sndash209S 1998

[3] ldquoNutrition and overweightrdquo in Healthy People 2010 chapter 19pp 1ndash15 Food and Drug Administration National Institutes ofHealth Hyattsville Md USA 2001 httpwwwcdcgovnchsdatahpdata2010hp2010 final review focus area 19pdf

[4] H Christopoulou-Aletra andN Papavramidou ldquoMethods usedby the Hippocratic physicians for weight reductionrdquo WorldJournal of Surgery vol 28 no 5 pp 513ndash517 2004

[5] D Haslam ldquoObesity a medical historyrdquoObesity Reviews vol 8supplement 1 pp 31ndash36 2007

[6] H Schwartz Never Satisfied A Cultural History of DietsFantasies and Fat The Free Press New York NY USA 1986

[7] Medico-Actuarial Mortality Investigation vol 1 Association ofLife Insurance Medical Directors The Actuarial Society ofAmerica New York NY USA 1912

[8] L IDublin andA J LothaTwenty-Five Years ofHealth ProgressA Study of the Mortality Experience among the IndustrialPolicyholders of the Metropolitan Life Insurance Company 1911to 1935 Metropolitan Life Insurance New York NY USA 1937

[9] Ideal weight for women Statistical bulletin of the MetropolitanLife Insurance Company 1943

[10] Metropolitan Life Insurance Company ldquoIdeal weights for menrdquoStatistical Bulletin of the Metropolitan Life Insurance Companyvol 23 pp 6ndash8 1942

Journal of Obesity 9

[11] Metropolitan Life Insurance Company ldquoNew weight standardsfor men and womenrdquo Statistical Bulletin-Metropolitan LifeInsurance Company vol 40 pp 1ndash4 1959

[12] Build and Blood Pressure Study vol 1 Society of ActuariesChicago Ill USA 1959

[13] Metropolitan Life Insurance Company ldquoMetropolitan heightand weight tablesrdquo Statistical Bulletin (Metropolitan Life Insur-ance Company) vol 64 pp 1ndash19 1983

[14] Build Study 1979 Society of Actuaries and Associations of LifeInsurance Medical Directors Chicago Ill USA 1980

[15] WHO ldquoPhysical status the use and interpretation of anthro-pometryrdquo Report of a WHO Expert Committee WHO Tech-nical Report Series 854 World Health Organization GenevaSwitzerland 1995

[16] US Department of Agriculture and US Department of Healthand Human Services Dietary Guidelines for Americans 2010US Government Printing Office Washington DC USA 2010

[17] H C Fish The Agentrsquos Manual of Life Assurance Mutual LifeInsurance Company of New York New York NY USA 1867

[18] US Department of Agriculture and US Department of Healthand Human Services Nutrition and Your Health DietaryGuidelines for Americans US Government Printing OfficeWashington DC USA 1980

[19] M A Quetelet A Treatise on Man and the Development of HisFaculties William and Robert Chambers Edinburgh UK 1842

[20] J Hutchinson ldquoOn the capacity of the lungs and on therespiratory functions with a view of establishing a precise andeasy method of detecting disease by the spirometerrdquo Medico-Chirurgical Transactions (London) vol 29 pp 137ndash161 1846

[21] ldquoObesity in perspectiverdquo in Fogarty International Center Serieson PreventiveMedicine G Bray Ed vol 2 ofDHEWPublicationno (NIH) 75-708 part 1 1975 httpssearchworksstanfordeduview2520869

[22] ldquoHealth implications of obesity National Institutes of Healthconsensus development conference statementrdquo Annals of Inter-nal Medicine vol 103 no 1 pp 147ndash151 1985

[23] ldquoHealth implications of obesity National institutes of healthconsensus development conference statementrdquo Annals of Inter-nal Medicine vol 103 no 6 part 2 pp 1073ndash1077 1985

[24] US Department of Agriculture and US Department of Healthand Human Services Nutrition and Your Health DietaryGuidelines for Americans Home and Garden Bulletin no 232US Government Printing Office Washington DC USA 1985

[25] US Department of Agriculture and US Department of HealthandHuman ServicesNutrition and YourHealth Dietary Guide-lines for Americans vol 232 of Home and Garden Bulletin USGovernment Printing Office Washington DC USA 1990

[26] WHO ldquoObesity preventing and managing the global epi-demicrdquo WHO Technical Report Series 894 World HealthOrganization Geneva Switzerland 2000

[27] US Department of Agriculture and US Department of Healthand Human Services Nutrition and Your Health DietaryGuidelines for Americans US Government Printing OfficeWashington DC USA 1995

[28] Congressional Record Public law 101ndash445 National NutritionMonitoring and Related Research Act of 1990 October 1990[Congressional Record vol 136 House Report no 101 (Com-mittee on Agriculture)] 1990

[29] WHOIASOIOTF The Asia-Pacific Perspective RedefiningObesity and Its Treatment Health Communications Mel-bourne Australia 2000

[30] WHO Expert Consultation ldquoAppropriate body-mass index forAsian populations and its implications for policy and interven-tion strategiesrdquoTheLancet vol 363 no 9403 pp 157ndash163 2004

[31] J Yudkin ldquoObesity a report of the royal college of physiciansrdquoJournal of the Royal Society of Medicine vol 76 no 6 pp 531ndash532 1983

[32] The Secretary of Health and Human Services Charter 2015Dietary Guidelines Advisory CommitteeThe Secretary ofHealthand Human Services Washington DC USA 2015

[33] W F Kemsley W Z Billewicz and A M Thomson ldquoA newweight-for-height standard based on British Anthropometricdatardquo British Journal of Preventive amp Social Medicine vol 16 pp189ndash195 1962

[34] R J Kuczmarski and K M Flegal ldquoCriteria for definition ofoverweight in transition background and recommendations forthe United Statesrdquo The American Journal of Clinical Nutritionvol 72 no 5 pp 1074ndash1081 2000

[35] R J Jarrett ldquoIs there an ideal body weightrdquo British MedicalJournal vol 293 no 6545 pp 493ndash495 1986

[36] K M Flegal C J Tabak and C L Ogden ldquoOverweightin children Definitions and interpretationrdquo Health EducationResearch vol 21 no 6 pp 755ndash760 2006

[37] T J Cole M C Bellizzi K M Flegal and W H DietzldquoEstablishing a standard definition for child overweight andobesity worldwide international surveyrdquo The British MedicalJournal vol 320 no 7244 pp 1240ndash1243 2000

Submit your manuscripts athttpwwwhindawicom

Stem CellsInternational

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

MEDIATORSINFLAMMATION

of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Behavioural Neurology

EndocrinologyInternational Journal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Disease Markers

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

BioMed Research International

OncologyJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Oxidative Medicine and Cellular Longevity

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

PPAR Research

The Scientific World JournalHindawi Publishing Corporation httpwwwhindawicom Volume 2014

Immunology ResearchHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Journal of

ObesityJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Computational and Mathematical Methods in Medicine

OphthalmologyJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Diabetes ResearchJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Research and TreatmentAIDS

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Gastroenterology Research and Practice

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Parkinsonrsquos Disease

Evidence-Based Complementary and Alternative Medicine

Volume 2014Hindawi Publishing Corporationhttpwwwhindawicom

6 Journal of Obesity

Table3Con

tinued

Year[ref]

Author

Criterialowast

Popu

latio

nScreening

Develo

pment

Milesto

neoutcome

2010

[16]

USDepartm

ento

fAgriculture

andUS

Departm

ento

fHealth

Edu

catio

nandWelfare

WHOInternationalC

lassificatio

nof

Weightb

ased

onBM

Ilevelwas

adop

tedforU

Spo

pulatio

nUSA

Matches

with

WHOandNIH

andNHLB

Icriteria

DietaryG

uidancefor

America

ns(7th

edition)lowastlowast

BMIclassification

matcheswith

WHOand

NIH

andNHLB

I1998

lowastCr

iteria

fortablegeneratio

nlowastlowastNexteditio

nisexpected

in2015

ldquoNationalN

utritionMon

itorin

gandRe

lated

Research

Acto

f1990rdquomdashPu

blicLaw101ndash445Title

IIISectio

n301sta

tedthatarepo

rtentitledldquoD

ietaryGu

idelinesfor

America

nsrdquos

hallcontainnu

trition

alanddietary

inform

ationandguidelines

forthe

generalpub

licandldquoshallbe

prom

oted

byeach

Federalagencyin

carrying

outany

Federalfoo

dnu

trition

orh

ealth

programrdquo[28]

Journal of Obesity 7

numbers came to the criteria of defining ldquooverweightrdquo as BMIge278 kgm2 for men and BMI ge273 for women [22] Thesecriteria matched with 20 or more above the ldquodesirablerdquoweight in the MLIC 1983 tables (from midpoint of the rangefor a medium-build person) [22] These definitions becamewidely accepted as the standards [22] Nevertheless numbersfor ranges of acceptable ldquonormalrdquo BMI were different fromthose based on the version of standard tables for example forMLIC 1959 264 (men) and 285 (women) and forMLIC 1983272 (men) and 269 (women) [23] Moreover the recom-mended requirement differed from the guidelines set up byFogarty Center and the Royal College of Physicians [21 35]Such discrepancies in the guidance pointed out the technicalproblems of weight to height tables the discrepancies ofmeasurements (shoes clothes and approximately 20 self-reported data in MLIC 1959 and 10 in MLIC 1983) andpopulation selection [35] It brought up an urgent need tostandardize definition of overweight and obesity and thesearch for weight to height index of body weight started

In 1985 the Department of Health and Human Services(HHS) and the Department of Agriculture (USDA) issuedthe second edition of ldquoDietary Guidelines for Americansrdquo [24]That document used the ldquodesirablerdquo weight to height tablesfromMLIC 1959 and translated the numbers into overweightlevel of BMI for men sim25-26 and for women sim24-25 [24 34]In the 1990 third edition tables for men and women werecombined into one and presented by two age groups whereldquounhealthyrdquo weight was translated into BMI ge 25 for ages 19ndash34 and ge27 for ages ge35 years [25 34]

In 1990 the ldquoNational Nutrition Monitoring and RelatedResearch Act of 1990rdquo Public Law 101ndash445 Title IIISection 301 stated that a report entitled ldquoDietary Guidelinesfor Americansrdquo shall contain nutritional and dietary informa-tion and guidelines for the general public and be publishedat least every five years [28] Each such report ldquoshall bepromoted by each Federal agency in carrying out any Federalfood nutrition or health programrdquo [28] Basically the lawstated that the definition of healthy weight or overweightfrom the Dietary Guidelines for Americans should be usedby the constituent Federal agencies [28]

In Geneva in 1995 WHO Expert Committee on PhysicalStatus published technical reportThe Use and Interpretationof Anthropometry [15] It was acknowledged that the basicanthropometry measurements of human body are weightand height [15] It was recommended to combine twobasic measurements weight and height into the body massindex (weightheight2) or ponderal index (weightheight3)for adults and three anthropometric indexes with consider-ation of age were described for children weight for heightheight for age and weight for age [15] The WHO ExpertCommittee on Physical Status proposed to classify differentlevels of BMI with cut-off points of 25 30 and 40 based onldquoarbitrarymethod of association betweenBMI andmortalityrdquo[15] WHO Expert Committee on Physical Status refer-enced the meta-analysis performed by Troiano et al whichincluded 17 studies with 37 substudies with 350000 menand gt38000 deaths plus six studies with 12 substudies with250000 women and 13700 deaths and presented the U-shapemortality rates that sharply increased when BMI lt185 and

Table 4 International classification of adults based on body massindex

Classification BMI (kgm2)Cut-off points Additional cut-off points

Underweight lt1850 lt185Severe thinness lt1600 lt160Moderate thinness 1600ndash1699 1600ndash1699Mild thinness 1700ndash1849 1700ndash1849

Normal 1850ndash2499 1850ndash22992300ndash2499

Overweight ge2500 ge2500

Preobese 2500ndash2999 2500ndash27492750ndash2999

Obese ge3000 ge3000

Class I 3000ndash3499 3000ndash32493250ndash3499

Class II 3500ndash3999 3500ndash37493750ndash3999

Class III ge4000 ge4000Source fromWHO 1995 WHO 2000 and WHO 2004 [15 26 29 30]

gt300 kgm2 with the acceptable BMI range as 185ndash2500 [15page 322] The WHO experts underscored that the cut-offswere chosen arbitrarily based on the ldquovisual inspection ofthe relationship between BMI and mortalityrdquo [15] curve forexample ldquothe cut-off of 30 is based on the point of flexionof the curverdquo [15] The authors suggested that this methodshould be revised in the future in terms of BMI associationwith health risk [15]

In 1995 the next step was taken to combine not justboth sexes but also age groups where ldquohealthyrdquo weight wastranslated in BMI ge25 for all adults in the fourth editionof ldquoDietary Guidelines for Americansrdquo [27] The report usedWHO criteria for publishing healthy weight ranges for menand women by each inch of height [27] The edition was veryimportant because it led to publishing the prevalence andtrends on overweight (BMI ge 25) preobese (BMI 250ndash299)class 1 (BMI 300ndash349) class 2 (BMI 350ndash399) and class3 (BMI ge 400) obese in the United States data from 1960to 1994 (NHANES I II and III) for first time to facilitatecomparison with international data [2]

Clinical Guidelines on the Identification Evaluation andTreatment of Overweight and Obesity in Adults (NIH Septem-ber 1998) defined overweight as a body mass index (BMI) of25 to 299 kgm2 and obesity as a BMI of ge30 kgm2 [2] Thepanel of experts came to this classification based on evidencefrom approximately 394 randomized controlled trials (RCTs)and multiple observational studies about BMI and risk ofmorbidity and mortality [2] The classification matched withone suggested by WHO [2 15]

In 2000 World Health Organization (WHO) definedoverweight and obesity as ldquothe disease in which excess bodyfat has accumulated to such an extent that health may beadversely affectedrdquo [26] and underscored that the practicaldefinition of obesity is based on the level of body massindex (BMI) [15 26]Themost recent version of international

8 Journal of Obesity

Table 5 Overweight and obese children and adolescents [16]

Category Children and adolescents (BMI for agepercentile rangelowast) Adults (BMI)

Underweight Less than the 5th percentile Less than 185 kgm2

Healthy weight 5th percentile to less than the 85th percentile 185 to 249 kgm2

Overweight 85th percentile to less than the 95th percentile 250 to 299 kgm2

Obese Equal to or greater than the 95th percentile 300 kgm2 or greaterlowastGrowth charts are available at httpwwwcdcgovgrowthcharts

classification for adults developed by WHO is presented inTable 4 [15 26]

BMI has never been a perfect index for children becauseit correlates with height In the United States Centers forDisease Control and Prevention (CDC) 2000 used fivenationally representative surveys to develop BMI charts forchildren in the United States the National Health Examina-tion Surveys (NHES) II and III in the 1960s the NationalHealth and Nutrition Examination Surveys (NHANES) I andII in the 1970s and NHANES III for the period of 1988ndash1994 Those charts included gender-specific BMI by singlemonth of age curves of growth Currently they are used inthe United States for children who are 2ndash19 years old todefine ldquooverweightrdquo as BMI ge95th percentile or ldquoat risk foroverweightrdquo if BMI is between 85th and 95th percentiles[26 36]

International surveys of six large and nationally repre-sentative cross-sectional growth studies from Brazil GreatBritain Hong Kong Netherlands Singapore and the UnitedStates were used by International Obesity Task Force (IOTF)to establish the cut-off points for overweight and obeseamong children and adolescents [37] In summary partic-ipants of IOTF agreed to link childhood overweight andobesity to the cut-offs for adults Based on each of the surveyspercentile curves were drawn in such a way that they passedthrough BMI cut-off points of 25 and 30 kgm2 at age of18 years and the resulting curves were averaged by age andgender to provide cut-off points for 2 through 18 years of age[37] This way less arbitrary and more internationally basedcut-offs were proposed [37]

In the current edition ofDietaryGuidelines for Americans2010 the BMI cut-offs are consistent with internationallyrecommended [16] By the Public Law 101ndash445 Title IIISection 301 all Federal agencies have made the transitionto define overweight and obesity as a BMI consistent withrecommendations in the current edition ofDietaryGuidelinesfor Americans [16 28] The table of weight category basedon BMI level from Dietary Guidelines for Americans 2010 ispresented in Table 5 [16]

4 Summary

There is nationwide and global epidemic of obesity As thefirst step to conquer a problem the concept of obesity shouldbe clearly understood through the historical process that ledto the worldwide accepted standard definition This paperpresents the history of developing current standard definitionof overweight and obesity Understanding the roots will lead

to the successful research on obesity with a goal to defeatnational and global epidemic

Competing Interests

The author declares that there are no competing interests

Acknowledgments

The author thanks Drs Michael Szarek Michael Walsh andElizabeth Helzner for assistance with development of thisproposal

References

[1] US Department of Health and Human Services The SurgeonGeneralrsquos Call to Action to Prevent and Decrease Overweight andObesity US Department ofHealth andHuman Services PublicHealth Service Office of the Surgeon General Rockville MdUSA 2001

[2] National Institutes of Health ldquoClinical guidelines on the identi-fication evaluation and treatment of overweight and obesity inadults-the evidence reportrdquoObesity Research vol 6 supplement2 pp 51Sndash209S 1998

[3] ldquoNutrition and overweightrdquo in Healthy People 2010 chapter 19pp 1ndash15 Food and Drug Administration National Institutes ofHealth Hyattsville Md USA 2001 httpwwwcdcgovnchsdatahpdata2010hp2010 final review focus area 19pdf

[4] H Christopoulou-Aletra andN Papavramidou ldquoMethods usedby the Hippocratic physicians for weight reductionrdquo WorldJournal of Surgery vol 28 no 5 pp 513ndash517 2004

[5] D Haslam ldquoObesity a medical historyrdquoObesity Reviews vol 8supplement 1 pp 31ndash36 2007

[6] H Schwartz Never Satisfied A Cultural History of DietsFantasies and Fat The Free Press New York NY USA 1986

[7] Medico-Actuarial Mortality Investigation vol 1 Association ofLife Insurance Medical Directors The Actuarial Society ofAmerica New York NY USA 1912

[8] L IDublin andA J LothaTwenty-Five Years ofHealth ProgressA Study of the Mortality Experience among the IndustrialPolicyholders of the Metropolitan Life Insurance Company 1911to 1935 Metropolitan Life Insurance New York NY USA 1937

[9] Ideal weight for women Statistical bulletin of the MetropolitanLife Insurance Company 1943

[10] Metropolitan Life Insurance Company ldquoIdeal weights for menrdquoStatistical Bulletin of the Metropolitan Life Insurance Companyvol 23 pp 6ndash8 1942

Journal of Obesity 9

[11] Metropolitan Life Insurance Company ldquoNew weight standardsfor men and womenrdquo Statistical Bulletin-Metropolitan LifeInsurance Company vol 40 pp 1ndash4 1959

[12] Build and Blood Pressure Study vol 1 Society of ActuariesChicago Ill USA 1959

[13] Metropolitan Life Insurance Company ldquoMetropolitan heightand weight tablesrdquo Statistical Bulletin (Metropolitan Life Insur-ance Company) vol 64 pp 1ndash19 1983

[14] Build Study 1979 Society of Actuaries and Associations of LifeInsurance Medical Directors Chicago Ill USA 1980

[15] WHO ldquoPhysical status the use and interpretation of anthro-pometryrdquo Report of a WHO Expert Committee WHO Tech-nical Report Series 854 World Health Organization GenevaSwitzerland 1995

[16] US Department of Agriculture and US Department of Healthand Human Services Dietary Guidelines for Americans 2010US Government Printing Office Washington DC USA 2010

[17] H C Fish The Agentrsquos Manual of Life Assurance Mutual LifeInsurance Company of New York New York NY USA 1867

[18] US Department of Agriculture and US Department of Healthand Human Services Nutrition and Your Health DietaryGuidelines for Americans US Government Printing OfficeWashington DC USA 1980

[19] M A Quetelet A Treatise on Man and the Development of HisFaculties William and Robert Chambers Edinburgh UK 1842

[20] J Hutchinson ldquoOn the capacity of the lungs and on therespiratory functions with a view of establishing a precise andeasy method of detecting disease by the spirometerrdquo Medico-Chirurgical Transactions (London) vol 29 pp 137ndash161 1846

[21] ldquoObesity in perspectiverdquo in Fogarty International Center Serieson PreventiveMedicine G Bray Ed vol 2 ofDHEWPublicationno (NIH) 75-708 part 1 1975 httpssearchworksstanfordeduview2520869

[22] ldquoHealth implications of obesity National Institutes of Healthconsensus development conference statementrdquo Annals of Inter-nal Medicine vol 103 no 1 pp 147ndash151 1985

[23] ldquoHealth implications of obesity National institutes of healthconsensus development conference statementrdquo Annals of Inter-nal Medicine vol 103 no 6 part 2 pp 1073ndash1077 1985

[24] US Department of Agriculture and US Department of Healthand Human Services Nutrition and Your Health DietaryGuidelines for Americans Home and Garden Bulletin no 232US Government Printing Office Washington DC USA 1985

[25] US Department of Agriculture and US Department of HealthandHuman ServicesNutrition and YourHealth Dietary Guide-lines for Americans vol 232 of Home and Garden Bulletin USGovernment Printing Office Washington DC USA 1990

[26] WHO ldquoObesity preventing and managing the global epi-demicrdquo WHO Technical Report Series 894 World HealthOrganization Geneva Switzerland 2000

[27] US Department of Agriculture and US Department of Healthand Human Services Nutrition and Your Health DietaryGuidelines for Americans US Government Printing OfficeWashington DC USA 1995

[28] Congressional Record Public law 101ndash445 National NutritionMonitoring and Related Research Act of 1990 October 1990[Congressional Record vol 136 House Report no 101 (Com-mittee on Agriculture)] 1990

[29] WHOIASOIOTF The Asia-Pacific Perspective RedefiningObesity and Its Treatment Health Communications Mel-bourne Australia 2000

[30] WHO Expert Consultation ldquoAppropriate body-mass index forAsian populations and its implications for policy and interven-tion strategiesrdquoTheLancet vol 363 no 9403 pp 157ndash163 2004

[31] J Yudkin ldquoObesity a report of the royal college of physiciansrdquoJournal of the Royal Society of Medicine vol 76 no 6 pp 531ndash532 1983

[32] The Secretary of Health and Human Services Charter 2015Dietary Guidelines Advisory CommitteeThe Secretary ofHealthand Human Services Washington DC USA 2015

[33] W F Kemsley W Z Billewicz and A M Thomson ldquoA newweight-for-height standard based on British Anthropometricdatardquo British Journal of Preventive amp Social Medicine vol 16 pp189ndash195 1962

[34] R J Kuczmarski and K M Flegal ldquoCriteria for definition ofoverweight in transition background and recommendations forthe United Statesrdquo The American Journal of Clinical Nutritionvol 72 no 5 pp 1074ndash1081 2000

[35] R J Jarrett ldquoIs there an ideal body weightrdquo British MedicalJournal vol 293 no 6545 pp 493ndash495 1986

[36] K M Flegal C J Tabak and C L Ogden ldquoOverweightin children Definitions and interpretationrdquo Health EducationResearch vol 21 no 6 pp 755ndash760 2006

[37] T J Cole M C Bellizzi K M Flegal and W H DietzldquoEstablishing a standard definition for child overweight andobesity worldwide international surveyrdquo The British MedicalJournal vol 320 no 7244 pp 1240ndash1243 2000

Submit your manuscripts athttpwwwhindawicom

Stem CellsInternational

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

MEDIATORSINFLAMMATION

of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Behavioural Neurology

EndocrinologyInternational Journal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Disease Markers

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

BioMed Research International

OncologyJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Oxidative Medicine and Cellular Longevity

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

PPAR Research

The Scientific World JournalHindawi Publishing Corporation httpwwwhindawicom Volume 2014

Immunology ResearchHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Journal of

ObesityJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Computational and Mathematical Methods in Medicine

OphthalmologyJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Diabetes ResearchJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Research and TreatmentAIDS

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Gastroenterology Research and Practice

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Parkinsonrsquos Disease

Evidence-Based Complementary and Alternative Medicine

Volume 2014Hindawi Publishing Corporationhttpwwwhindawicom

Journal of Obesity 7

numbers came to the criteria of defining ldquooverweightrdquo as BMIge278 kgm2 for men and BMI ge273 for women [22] Thesecriteria matched with 20 or more above the ldquodesirablerdquoweight in the MLIC 1983 tables (from midpoint of the rangefor a medium-build person) [22] These definitions becamewidely accepted as the standards [22] Nevertheless numbersfor ranges of acceptable ldquonormalrdquo BMI were different fromthose based on the version of standard tables for example forMLIC 1959 264 (men) and 285 (women) and forMLIC 1983272 (men) and 269 (women) [23] Moreover the recom-mended requirement differed from the guidelines set up byFogarty Center and the Royal College of Physicians [21 35]Such discrepancies in the guidance pointed out the technicalproblems of weight to height tables the discrepancies ofmeasurements (shoes clothes and approximately 20 self-reported data in MLIC 1959 and 10 in MLIC 1983) andpopulation selection [35] It brought up an urgent need tostandardize definition of overweight and obesity and thesearch for weight to height index of body weight started

In 1985 the Department of Health and Human Services(HHS) and the Department of Agriculture (USDA) issuedthe second edition of ldquoDietary Guidelines for Americansrdquo [24]That document used the ldquodesirablerdquo weight to height tablesfromMLIC 1959 and translated the numbers into overweightlevel of BMI for men sim25-26 and for women sim24-25 [24 34]In the 1990 third edition tables for men and women werecombined into one and presented by two age groups whereldquounhealthyrdquo weight was translated into BMI ge 25 for ages 19ndash34 and ge27 for ages ge35 years [25 34]

In 1990 the ldquoNational Nutrition Monitoring and RelatedResearch Act of 1990rdquo Public Law 101ndash445 Title IIISection 301 stated that a report entitled ldquoDietary Guidelinesfor Americansrdquo shall contain nutritional and dietary informa-tion and guidelines for the general public and be publishedat least every five years [28] Each such report ldquoshall bepromoted by each Federal agency in carrying out any Federalfood nutrition or health programrdquo [28] Basically the lawstated that the definition of healthy weight or overweightfrom the Dietary Guidelines for Americans should be usedby the constituent Federal agencies [28]

In Geneva in 1995 WHO Expert Committee on PhysicalStatus published technical reportThe Use and Interpretationof Anthropometry [15] It was acknowledged that the basicanthropometry measurements of human body are weightand height [15] It was recommended to combine twobasic measurements weight and height into the body massindex (weightheight2) or ponderal index (weightheight3)for adults and three anthropometric indexes with consider-ation of age were described for children weight for heightheight for age and weight for age [15] The WHO ExpertCommittee on Physical Status proposed to classify differentlevels of BMI with cut-off points of 25 30 and 40 based onldquoarbitrarymethod of association betweenBMI andmortalityrdquo[15] WHO Expert Committee on Physical Status refer-enced the meta-analysis performed by Troiano et al whichincluded 17 studies with 37 substudies with 350000 menand gt38000 deaths plus six studies with 12 substudies with250000 women and 13700 deaths and presented the U-shapemortality rates that sharply increased when BMI lt185 and

Table 4 International classification of adults based on body massindex

Classification BMI (kgm2)Cut-off points Additional cut-off points

Underweight lt1850 lt185Severe thinness lt1600 lt160Moderate thinness 1600ndash1699 1600ndash1699Mild thinness 1700ndash1849 1700ndash1849

Normal 1850ndash2499 1850ndash22992300ndash2499

Overweight ge2500 ge2500

Preobese 2500ndash2999 2500ndash27492750ndash2999

Obese ge3000 ge3000

Class I 3000ndash3499 3000ndash32493250ndash3499

Class II 3500ndash3999 3500ndash37493750ndash3999

Class III ge4000 ge4000Source fromWHO 1995 WHO 2000 and WHO 2004 [15 26 29 30]

gt300 kgm2 with the acceptable BMI range as 185ndash2500 [15page 322] The WHO experts underscored that the cut-offswere chosen arbitrarily based on the ldquovisual inspection ofthe relationship between BMI and mortalityrdquo [15] curve forexample ldquothe cut-off of 30 is based on the point of flexionof the curverdquo [15] The authors suggested that this methodshould be revised in the future in terms of BMI associationwith health risk [15]

In 1995 the next step was taken to combine not justboth sexes but also age groups where ldquohealthyrdquo weight wastranslated in BMI ge25 for all adults in the fourth editionof ldquoDietary Guidelines for Americansrdquo [27] The report usedWHO criteria for publishing healthy weight ranges for menand women by each inch of height [27] The edition was veryimportant because it led to publishing the prevalence andtrends on overweight (BMI ge 25) preobese (BMI 250ndash299)class 1 (BMI 300ndash349) class 2 (BMI 350ndash399) and class3 (BMI ge 400) obese in the United States data from 1960to 1994 (NHANES I II and III) for first time to facilitatecomparison with international data [2]

Clinical Guidelines on the Identification Evaluation andTreatment of Overweight and Obesity in Adults (NIH Septem-ber 1998) defined overweight as a body mass index (BMI) of25 to 299 kgm2 and obesity as a BMI of ge30 kgm2 [2] Thepanel of experts came to this classification based on evidencefrom approximately 394 randomized controlled trials (RCTs)and multiple observational studies about BMI and risk ofmorbidity and mortality [2] The classification matched withone suggested by WHO [2 15]

In 2000 World Health Organization (WHO) definedoverweight and obesity as ldquothe disease in which excess bodyfat has accumulated to such an extent that health may beadversely affectedrdquo [26] and underscored that the practicaldefinition of obesity is based on the level of body massindex (BMI) [15 26]Themost recent version of international

8 Journal of Obesity

Table 5 Overweight and obese children and adolescents [16]

Category Children and adolescents (BMI for agepercentile rangelowast) Adults (BMI)

Underweight Less than the 5th percentile Less than 185 kgm2

Healthy weight 5th percentile to less than the 85th percentile 185 to 249 kgm2

Overweight 85th percentile to less than the 95th percentile 250 to 299 kgm2

Obese Equal to or greater than the 95th percentile 300 kgm2 or greaterlowastGrowth charts are available at httpwwwcdcgovgrowthcharts

classification for adults developed by WHO is presented inTable 4 [15 26]

BMI has never been a perfect index for children becauseit correlates with height In the United States Centers forDisease Control and Prevention (CDC) 2000 used fivenationally representative surveys to develop BMI charts forchildren in the United States the National Health Examina-tion Surveys (NHES) II and III in the 1960s the NationalHealth and Nutrition Examination Surveys (NHANES) I andII in the 1970s and NHANES III for the period of 1988ndash1994 Those charts included gender-specific BMI by singlemonth of age curves of growth Currently they are used inthe United States for children who are 2ndash19 years old todefine ldquooverweightrdquo as BMI ge95th percentile or ldquoat risk foroverweightrdquo if BMI is between 85th and 95th percentiles[26 36]

International surveys of six large and nationally repre-sentative cross-sectional growth studies from Brazil GreatBritain Hong Kong Netherlands Singapore and the UnitedStates were used by International Obesity Task Force (IOTF)to establish the cut-off points for overweight and obeseamong children and adolescents [37] In summary partic-ipants of IOTF agreed to link childhood overweight andobesity to the cut-offs for adults Based on each of the surveyspercentile curves were drawn in such a way that they passedthrough BMI cut-off points of 25 and 30 kgm2 at age of18 years and the resulting curves were averaged by age andgender to provide cut-off points for 2 through 18 years of age[37] This way less arbitrary and more internationally basedcut-offs were proposed [37]

In the current edition ofDietaryGuidelines for Americans2010 the BMI cut-offs are consistent with internationallyrecommended [16] By the Public Law 101ndash445 Title IIISection 301 all Federal agencies have made the transitionto define overweight and obesity as a BMI consistent withrecommendations in the current edition ofDietaryGuidelinesfor Americans [16 28] The table of weight category basedon BMI level from Dietary Guidelines for Americans 2010 ispresented in Table 5 [16]

4 Summary

There is nationwide and global epidemic of obesity As thefirst step to conquer a problem the concept of obesity shouldbe clearly understood through the historical process that ledto the worldwide accepted standard definition This paperpresents the history of developing current standard definitionof overweight and obesity Understanding the roots will lead

to the successful research on obesity with a goal to defeatnational and global epidemic

Competing Interests

The author declares that there are no competing interests

Acknowledgments

The author thanks Drs Michael Szarek Michael Walsh andElizabeth Helzner for assistance with development of thisproposal

References

[1] US Department of Health and Human Services The SurgeonGeneralrsquos Call to Action to Prevent and Decrease Overweight andObesity US Department ofHealth andHuman Services PublicHealth Service Office of the Surgeon General Rockville MdUSA 2001

[2] National Institutes of Health ldquoClinical guidelines on the identi-fication evaluation and treatment of overweight and obesity inadults-the evidence reportrdquoObesity Research vol 6 supplement2 pp 51Sndash209S 1998

[3] ldquoNutrition and overweightrdquo in Healthy People 2010 chapter 19pp 1ndash15 Food and Drug Administration National Institutes ofHealth Hyattsville Md USA 2001 httpwwwcdcgovnchsdatahpdata2010hp2010 final review focus area 19pdf

[4] H Christopoulou-Aletra andN Papavramidou ldquoMethods usedby the Hippocratic physicians for weight reductionrdquo WorldJournal of Surgery vol 28 no 5 pp 513ndash517 2004

[5] D Haslam ldquoObesity a medical historyrdquoObesity Reviews vol 8supplement 1 pp 31ndash36 2007

[6] H Schwartz Never Satisfied A Cultural History of DietsFantasies and Fat The Free Press New York NY USA 1986

[7] Medico-Actuarial Mortality Investigation vol 1 Association ofLife Insurance Medical Directors The Actuarial Society ofAmerica New York NY USA 1912

[8] L IDublin andA J LothaTwenty-Five Years ofHealth ProgressA Study of the Mortality Experience among the IndustrialPolicyholders of the Metropolitan Life Insurance Company 1911to 1935 Metropolitan Life Insurance New York NY USA 1937

[9] Ideal weight for women Statistical bulletin of the MetropolitanLife Insurance Company 1943

[10] Metropolitan Life Insurance Company ldquoIdeal weights for menrdquoStatistical Bulletin of the Metropolitan Life Insurance Companyvol 23 pp 6ndash8 1942

Journal of Obesity 9

[11] Metropolitan Life Insurance Company ldquoNew weight standardsfor men and womenrdquo Statistical Bulletin-Metropolitan LifeInsurance Company vol 40 pp 1ndash4 1959

[12] Build and Blood Pressure Study vol 1 Society of ActuariesChicago Ill USA 1959

[13] Metropolitan Life Insurance Company ldquoMetropolitan heightand weight tablesrdquo Statistical Bulletin (Metropolitan Life Insur-ance Company) vol 64 pp 1ndash19 1983

[14] Build Study 1979 Society of Actuaries and Associations of LifeInsurance Medical Directors Chicago Ill USA 1980

[15] WHO ldquoPhysical status the use and interpretation of anthro-pometryrdquo Report of a WHO Expert Committee WHO Tech-nical Report Series 854 World Health Organization GenevaSwitzerland 1995

[16] US Department of Agriculture and US Department of Healthand Human Services Dietary Guidelines for Americans 2010US Government Printing Office Washington DC USA 2010

[17] H C Fish The Agentrsquos Manual of Life Assurance Mutual LifeInsurance Company of New York New York NY USA 1867

[18] US Department of Agriculture and US Department of Healthand Human Services Nutrition and Your Health DietaryGuidelines for Americans US Government Printing OfficeWashington DC USA 1980

[19] M A Quetelet A Treatise on Man and the Development of HisFaculties William and Robert Chambers Edinburgh UK 1842

[20] J Hutchinson ldquoOn the capacity of the lungs and on therespiratory functions with a view of establishing a precise andeasy method of detecting disease by the spirometerrdquo Medico-Chirurgical Transactions (London) vol 29 pp 137ndash161 1846

[21] ldquoObesity in perspectiverdquo in Fogarty International Center Serieson PreventiveMedicine G Bray Ed vol 2 ofDHEWPublicationno (NIH) 75-708 part 1 1975 httpssearchworksstanfordeduview2520869

[22] ldquoHealth implications of obesity National Institutes of Healthconsensus development conference statementrdquo Annals of Inter-nal Medicine vol 103 no 1 pp 147ndash151 1985

[23] ldquoHealth implications of obesity National institutes of healthconsensus development conference statementrdquo Annals of Inter-nal Medicine vol 103 no 6 part 2 pp 1073ndash1077 1985

[24] US Department of Agriculture and US Department of Healthand Human Services Nutrition and Your Health DietaryGuidelines for Americans Home and Garden Bulletin no 232US Government Printing Office Washington DC USA 1985

[25] US Department of Agriculture and US Department of HealthandHuman ServicesNutrition and YourHealth Dietary Guide-lines for Americans vol 232 of Home and Garden Bulletin USGovernment Printing Office Washington DC USA 1990

[26] WHO ldquoObesity preventing and managing the global epi-demicrdquo WHO Technical Report Series 894 World HealthOrganization Geneva Switzerland 2000

[27] US Department of Agriculture and US Department of Healthand Human Services Nutrition and Your Health DietaryGuidelines for Americans US Government Printing OfficeWashington DC USA 1995

[28] Congressional Record Public law 101ndash445 National NutritionMonitoring and Related Research Act of 1990 October 1990[Congressional Record vol 136 House Report no 101 (Com-mittee on Agriculture)] 1990

[29] WHOIASOIOTF The Asia-Pacific Perspective RedefiningObesity and Its Treatment Health Communications Mel-bourne Australia 2000

[30] WHO Expert Consultation ldquoAppropriate body-mass index forAsian populations and its implications for policy and interven-tion strategiesrdquoTheLancet vol 363 no 9403 pp 157ndash163 2004

[31] J Yudkin ldquoObesity a report of the royal college of physiciansrdquoJournal of the Royal Society of Medicine vol 76 no 6 pp 531ndash532 1983

[32] The Secretary of Health and Human Services Charter 2015Dietary Guidelines Advisory CommitteeThe Secretary ofHealthand Human Services Washington DC USA 2015

[33] W F Kemsley W Z Billewicz and A M Thomson ldquoA newweight-for-height standard based on British Anthropometricdatardquo British Journal of Preventive amp Social Medicine vol 16 pp189ndash195 1962

[34] R J Kuczmarski and K M Flegal ldquoCriteria for definition ofoverweight in transition background and recommendations forthe United Statesrdquo The American Journal of Clinical Nutritionvol 72 no 5 pp 1074ndash1081 2000

[35] R J Jarrett ldquoIs there an ideal body weightrdquo British MedicalJournal vol 293 no 6545 pp 493ndash495 1986

[36] K M Flegal C J Tabak and C L Ogden ldquoOverweightin children Definitions and interpretationrdquo Health EducationResearch vol 21 no 6 pp 755ndash760 2006

[37] T J Cole M C Bellizzi K M Flegal and W H DietzldquoEstablishing a standard definition for child overweight andobesity worldwide international surveyrdquo The British MedicalJournal vol 320 no 7244 pp 1240ndash1243 2000

Submit your manuscripts athttpwwwhindawicom

Stem CellsInternational

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

MEDIATORSINFLAMMATION

of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Behavioural Neurology

EndocrinologyInternational Journal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Disease Markers

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

BioMed Research International

OncologyJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Oxidative Medicine and Cellular Longevity

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

PPAR Research

The Scientific World JournalHindawi Publishing Corporation httpwwwhindawicom Volume 2014

Immunology ResearchHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Journal of

ObesityJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Computational and Mathematical Methods in Medicine

OphthalmologyJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Diabetes ResearchJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Research and TreatmentAIDS

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Gastroenterology Research and Practice

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Parkinsonrsquos Disease

Evidence-Based Complementary and Alternative Medicine

Volume 2014Hindawi Publishing Corporationhttpwwwhindawicom

8 Journal of Obesity

Table 5 Overweight and obese children and adolescents [16]

Category Children and adolescents (BMI for agepercentile rangelowast) Adults (BMI)

Underweight Less than the 5th percentile Less than 185 kgm2

Healthy weight 5th percentile to less than the 85th percentile 185 to 249 kgm2

Overweight 85th percentile to less than the 95th percentile 250 to 299 kgm2

Obese Equal to or greater than the 95th percentile 300 kgm2 or greaterlowastGrowth charts are available at httpwwwcdcgovgrowthcharts

classification for adults developed by WHO is presented inTable 4 [15 26]

BMI has never been a perfect index for children becauseit correlates with height In the United States Centers forDisease Control and Prevention (CDC) 2000 used fivenationally representative surveys to develop BMI charts forchildren in the United States the National Health Examina-tion Surveys (NHES) II and III in the 1960s the NationalHealth and Nutrition Examination Surveys (NHANES) I andII in the 1970s and NHANES III for the period of 1988ndash1994 Those charts included gender-specific BMI by singlemonth of age curves of growth Currently they are used inthe United States for children who are 2ndash19 years old todefine ldquooverweightrdquo as BMI ge95th percentile or ldquoat risk foroverweightrdquo if BMI is between 85th and 95th percentiles[26 36]

International surveys of six large and nationally repre-sentative cross-sectional growth studies from Brazil GreatBritain Hong Kong Netherlands Singapore and the UnitedStates were used by International Obesity Task Force (IOTF)to establish the cut-off points for overweight and obeseamong children and adolescents [37] In summary partic-ipants of IOTF agreed to link childhood overweight andobesity to the cut-offs for adults Based on each of the surveyspercentile curves were drawn in such a way that they passedthrough BMI cut-off points of 25 and 30 kgm2 at age of18 years and the resulting curves were averaged by age andgender to provide cut-off points for 2 through 18 years of age[37] This way less arbitrary and more internationally basedcut-offs were proposed [37]

In the current edition ofDietaryGuidelines for Americans2010 the BMI cut-offs are consistent with internationallyrecommended [16] By the Public Law 101ndash445 Title IIISection 301 all Federal agencies have made the transitionto define overweight and obesity as a BMI consistent withrecommendations in the current edition ofDietaryGuidelinesfor Americans [16 28] The table of weight category basedon BMI level from Dietary Guidelines for Americans 2010 ispresented in Table 5 [16]

4 Summary

There is nationwide and global epidemic of obesity As thefirst step to conquer a problem the concept of obesity shouldbe clearly understood through the historical process that ledto the worldwide accepted standard definition This paperpresents the history of developing current standard definitionof overweight and obesity Understanding the roots will lead

to the successful research on obesity with a goal to defeatnational and global epidemic

Competing Interests

The author declares that there are no competing interests

Acknowledgments

The author thanks Drs Michael Szarek Michael Walsh andElizabeth Helzner for assistance with development of thisproposal

References

[1] US Department of Health and Human Services The SurgeonGeneralrsquos Call to Action to Prevent and Decrease Overweight andObesity US Department ofHealth andHuman Services PublicHealth Service Office of the Surgeon General Rockville MdUSA 2001

[2] National Institutes of Health ldquoClinical guidelines on the identi-fication evaluation and treatment of overweight and obesity inadults-the evidence reportrdquoObesity Research vol 6 supplement2 pp 51Sndash209S 1998

[3] ldquoNutrition and overweightrdquo in Healthy People 2010 chapter 19pp 1ndash15 Food and Drug Administration National Institutes ofHealth Hyattsville Md USA 2001 httpwwwcdcgovnchsdatahpdata2010hp2010 final review focus area 19pdf

[4] H Christopoulou-Aletra andN Papavramidou ldquoMethods usedby the Hippocratic physicians for weight reductionrdquo WorldJournal of Surgery vol 28 no 5 pp 513ndash517 2004

[5] D Haslam ldquoObesity a medical historyrdquoObesity Reviews vol 8supplement 1 pp 31ndash36 2007

[6] H Schwartz Never Satisfied A Cultural History of DietsFantasies and Fat The Free Press New York NY USA 1986

[7] Medico-Actuarial Mortality Investigation vol 1 Association ofLife Insurance Medical Directors The Actuarial Society ofAmerica New York NY USA 1912

[8] L IDublin andA J LothaTwenty-Five Years ofHealth ProgressA Study of the Mortality Experience among the IndustrialPolicyholders of the Metropolitan Life Insurance Company 1911to 1935 Metropolitan Life Insurance New York NY USA 1937

[9] Ideal weight for women Statistical bulletin of the MetropolitanLife Insurance Company 1943

[10] Metropolitan Life Insurance Company ldquoIdeal weights for menrdquoStatistical Bulletin of the Metropolitan Life Insurance Companyvol 23 pp 6ndash8 1942

Journal of Obesity 9

[11] Metropolitan Life Insurance Company ldquoNew weight standardsfor men and womenrdquo Statistical Bulletin-Metropolitan LifeInsurance Company vol 40 pp 1ndash4 1959

[12] Build and Blood Pressure Study vol 1 Society of ActuariesChicago Ill USA 1959

[13] Metropolitan Life Insurance Company ldquoMetropolitan heightand weight tablesrdquo Statistical Bulletin (Metropolitan Life Insur-ance Company) vol 64 pp 1ndash19 1983

[14] Build Study 1979 Society of Actuaries and Associations of LifeInsurance Medical Directors Chicago Ill USA 1980

[15] WHO ldquoPhysical status the use and interpretation of anthro-pometryrdquo Report of a WHO Expert Committee WHO Tech-nical Report Series 854 World Health Organization GenevaSwitzerland 1995

[16] US Department of Agriculture and US Department of Healthand Human Services Dietary Guidelines for Americans 2010US Government Printing Office Washington DC USA 2010

[17] H C Fish The Agentrsquos Manual of Life Assurance Mutual LifeInsurance Company of New York New York NY USA 1867

[18] US Department of Agriculture and US Department of Healthand Human Services Nutrition and Your Health DietaryGuidelines for Americans US Government Printing OfficeWashington DC USA 1980

[19] M A Quetelet A Treatise on Man and the Development of HisFaculties William and Robert Chambers Edinburgh UK 1842

[20] J Hutchinson ldquoOn the capacity of the lungs and on therespiratory functions with a view of establishing a precise andeasy method of detecting disease by the spirometerrdquo Medico-Chirurgical Transactions (London) vol 29 pp 137ndash161 1846

[21] ldquoObesity in perspectiverdquo in Fogarty International Center Serieson PreventiveMedicine G Bray Ed vol 2 ofDHEWPublicationno (NIH) 75-708 part 1 1975 httpssearchworksstanfordeduview2520869

[22] ldquoHealth implications of obesity National Institutes of Healthconsensus development conference statementrdquo Annals of Inter-nal Medicine vol 103 no 1 pp 147ndash151 1985

[23] ldquoHealth implications of obesity National institutes of healthconsensus development conference statementrdquo Annals of Inter-nal Medicine vol 103 no 6 part 2 pp 1073ndash1077 1985

[24] US Department of Agriculture and US Department of Healthand Human Services Nutrition and Your Health DietaryGuidelines for Americans Home and Garden Bulletin no 232US Government Printing Office Washington DC USA 1985

[25] US Department of Agriculture and US Department of HealthandHuman ServicesNutrition and YourHealth Dietary Guide-lines for Americans vol 232 of Home and Garden Bulletin USGovernment Printing Office Washington DC USA 1990

[26] WHO ldquoObesity preventing and managing the global epi-demicrdquo WHO Technical Report Series 894 World HealthOrganization Geneva Switzerland 2000

[27] US Department of Agriculture and US Department of Healthand Human Services Nutrition and Your Health DietaryGuidelines for Americans US Government Printing OfficeWashington DC USA 1995

[28] Congressional Record Public law 101ndash445 National NutritionMonitoring and Related Research Act of 1990 October 1990[Congressional Record vol 136 House Report no 101 (Com-mittee on Agriculture)] 1990

[29] WHOIASOIOTF The Asia-Pacific Perspective RedefiningObesity and Its Treatment Health Communications Mel-bourne Australia 2000

[30] WHO Expert Consultation ldquoAppropriate body-mass index forAsian populations and its implications for policy and interven-tion strategiesrdquoTheLancet vol 363 no 9403 pp 157ndash163 2004

[31] J Yudkin ldquoObesity a report of the royal college of physiciansrdquoJournal of the Royal Society of Medicine vol 76 no 6 pp 531ndash532 1983

[32] The Secretary of Health and Human Services Charter 2015Dietary Guidelines Advisory CommitteeThe Secretary ofHealthand Human Services Washington DC USA 2015

[33] W F Kemsley W Z Billewicz and A M Thomson ldquoA newweight-for-height standard based on British Anthropometricdatardquo British Journal of Preventive amp Social Medicine vol 16 pp189ndash195 1962

[34] R J Kuczmarski and K M Flegal ldquoCriteria for definition ofoverweight in transition background and recommendations forthe United Statesrdquo The American Journal of Clinical Nutritionvol 72 no 5 pp 1074ndash1081 2000

[35] R J Jarrett ldquoIs there an ideal body weightrdquo British MedicalJournal vol 293 no 6545 pp 493ndash495 1986

[36] K M Flegal C J Tabak and C L Ogden ldquoOverweightin children Definitions and interpretationrdquo Health EducationResearch vol 21 no 6 pp 755ndash760 2006

[37] T J Cole M C Bellizzi K M Flegal and W H DietzldquoEstablishing a standard definition for child overweight andobesity worldwide international surveyrdquo The British MedicalJournal vol 320 no 7244 pp 1240ndash1243 2000

Submit your manuscripts athttpwwwhindawicom

Stem CellsInternational

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

MEDIATORSINFLAMMATION

of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Behavioural Neurology

EndocrinologyInternational Journal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Disease Markers

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

BioMed Research International

OncologyJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Oxidative Medicine and Cellular Longevity

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

PPAR Research

The Scientific World JournalHindawi Publishing Corporation httpwwwhindawicom Volume 2014

Immunology ResearchHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Journal of

ObesityJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Computational and Mathematical Methods in Medicine

OphthalmologyJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Diabetes ResearchJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Research and TreatmentAIDS

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Gastroenterology Research and Practice

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Parkinsonrsquos Disease

Evidence-Based Complementary and Alternative Medicine

Volume 2014Hindawi Publishing Corporationhttpwwwhindawicom

Journal of Obesity 9

[11] Metropolitan Life Insurance Company ldquoNew weight standardsfor men and womenrdquo Statistical Bulletin-Metropolitan LifeInsurance Company vol 40 pp 1ndash4 1959

[12] Build and Blood Pressure Study vol 1 Society of ActuariesChicago Ill USA 1959

[13] Metropolitan Life Insurance Company ldquoMetropolitan heightand weight tablesrdquo Statistical Bulletin (Metropolitan Life Insur-ance Company) vol 64 pp 1ndash19 1983

[14] Build Study 1979 Society of Actuaries and Associations of LifeInsurance Medical Directors Chicago Ill USA 1980

[15] WHO ldquoPhysical status the use and interpretation of anthro-pometryrdquo Report of a WHO Expert Committee WHO Tech-nical Report Series 854 World Health Organization GenevaSwitzerland 1995

[16] US Department of Agriculture and US Department of Healthand Human Services Dietary Guidelines for Americans 2010US Government Printing Office Washington DC USA 2010

[17] H C Fish The Agentrsquos Manual of Life Assurance Mutual LifeInsurance Company of New York New York NY USA 1867

[18] US Department of Agriculture and US Department of Healthand Human Services Nutrition and Your Health DietaryGuidelines for Americans US Government Printing OfficeWashington DC USA 1980

[19] M A Quetelet A Treatise on Man and the Development of HisFaculties William and Robert Chambers Edinburgh UK 1842

[20] J Hutchinson ldquoOn the capacity of the lungs and on therespiratory functions with a view of establishing a precise andeasy method of detecting disease by the spirometerrdquo Medico-Chirurgical Transactions (London) vol 29 pp 137ndash161 1846

[21] ldquoObesity in perspectiverdquo in Fogarty International Center Serieson PreventiveMedicine G Bray Ed vol 2 ofDHEWPublicationno (NIH) 75-708 part 1 1975 httpssearchworksstanfordeduview2520869

[22] ldquoHealth implications of obesity National Institutes of Healthconsensus development conference statementrdquo Annals of Inter-nal Medicine vol 103 no 1 pp 147ndash151 1985

[23] ldquoHealth implications of obesity National institutes of healthconsensus development conference statementrdquo Annals of Inter-nal Medicine vol 103 no 6 part 2 pp 1073ndash1077 1985

[24] US Department of Agriculture and US Department of Healthand Human Services Nutrition and Your Health DietaryGuidelines for Americans Home and Garden Bulletin no 232US Government Printing Office Washington DC USA 1985

[25] US Department of Agriculture and US Department of HealthandHuman ServicesNutrition and YourHealth Dietary Guide-lines for Americans vol 232 of Home and Garden Bulletin USGovernment Printing Office Washington DC USA 1990

[26] WHO ldquoObesity preventing and managing the global epi-demicrdquo WHO Technical Report Series 894 World HealthOrganization Geneva Switzerland 2000

[27] US Department of Agriculture and US Department of Healthand Human Services Nutrition and Your Health DietaryGuidelines for Americans US Government Printing OfficeWashington DC USA 1995

[28] Congressional Record Public law 101ndash445 National NutritionMonitoring and Related Research Act of 1990 October 1990[Congressional Record vol 136 House Report no 101 (Com-mittee on Agriculture)] 1990

[29] WHOIASOIOTF The Asia-Pacific Perspective RedefiningObesity and Its Treatment Health Communications Mel-bourne Australia 2000

[30] WHO Expert Consultation ldquoAppropriate body-mass index forAsian populations and its implications for policy and interven-tion strategiesrdquoTheLancet vol 363 no 9403 pp 157ndash163 2004

[31] J Yudkin ldquoObesity a report of the royal college of physiciansrdquoJournal of the Royal Society of Medicine vol 76 no 6 pp 531ndash532 1983

[32] The Secretary of Health and Human Services Charter 2015Dietary Guidelines Advisory CommitteeThe Secretary ofHealthand Human Services Washington DC USA 2015

[33] W F Kemsley W Z Billewicz and A M Thomson ldquoA newweight-for-height standard based on British Anthropometricdatardquo British Journal of Preventive amp Social Medicine vol 16 pp189ndash195 1962

[34] R J Kuczmarski and K M Flegal ldquoCriteria for definition ofoverweight in transition background and recommendations forthe United Statesrdquo The American Journal of Clinical Nutritionvol 72 no 5 pp 1074ndash1081 2000

[35] R J Jarrett ldquoIs there an ideal body weightrdquo British MedicalJournal vol 293 no 6545 pp 493ndash495 1986

[36] K M Flegal C J Tabak and C L Ogden ldquoOverweightin children Definitions and interpretationrdquo Health EducationResearch vol 21 no 6 pp 755ndash760 2006

[37] T J Cole M C Bellizzi K M Flegal and W H DietzldquoEstablishing a standard definition for child overweight andobesity worldwide international surveyrdquo The British MedicalJournal vol 320 no 7244 pp 1240ndash1243 2000

Submit your manuscripts athttpwwwhindawicom

Stem CellsInternational

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

MEDIATORSINFLAMMATION

of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Behavioural Neurology

EndocrinologyInternational Journal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Disease Markers

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

BioMed Research International

OncologyJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Oxidative Medicine and Cellular Longevity

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

PPAR Research

The Scientific World JournalHindawi Publishing Corporation httpwwwhindawicom Volume 2014

Immunology ResearchHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Journal of

ObesityJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Computational and Mathematical Methods in Medicine

OphthalmologyJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Diabetes ResearchJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Research and TreatmentAIDS

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Gastroenterology Research and Practice

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Parkinsonrsquos Disease

Evidence-Based Complementary and Alternative Medicine

Volume 2014Hindawi Publishing Corporationhttpwwwhindawicom

Submit your manuscripts athttpwwwhindawicom

Stem CellsInternational

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

MEDIATORSINFLAMMATION

of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Behavioural Neurology

EndocrinologyInternational Journal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Disease Markers

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

BioMed Research International

OncologyJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Oxidative Medicine and Cellular Longevity

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

PPAR Research

The Scientific World JournalHindawi Publishing Corporation httpwwwhindawicom Volume 2014

Immunology ResearchHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Journal of

ObesityJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Computational and Mathematical Methods in Medicine

OphthalmologyJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Diabetes ResearchJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Research and TreatmentAIDS

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Gastroenterology Research and Practice

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Parkinsonrsquos Disease

Evidence-Based Complementary and Alternative Medicine

Volume 2014Hindawi Publishing Corporationhttpwwwhindawicom