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Current concept of obesity

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Mazzeo F.,: Current concept of obesity Sport Science 9 (2016) issue 2

Current concept of obesity

Filomena Mazzeo

Department of Science and Technology, University of Naples Parthenope, Italy

Abstract

“Globesity” is a word used by the World Health Organization (WHO) to describe the global
epidemic of overweight and obesity. The gain weight is due to numerous factors such as an
unhealthy lifestyle, a wrong diet, a lack of exercise, the change in way to live and genetic
factors. It is reported that the accumulation of fat in the body starts in childhood and changes
depending on sex, age and ethnicity. The illness linked to high body fat are obesity, type 2
diabetes, osteoporosis, depression, and cancer of the breast and colon. There are different tests
that measure the quantity of body fat but the most used is the Body Mass Index. According to
it, a person is obese when his BMI is equal or superior to 30 points. Researchers showed that
diet and exercise play an important role in the treatment and prevention of obesity in patients
with obesity as useful variables to predict CVD risk beyond adiposity and emerging evidence
showed also the importance of cardiorespiratory fitness, skeletal muscle mass and strength.
Regular exercise (and proper nutrition) can help reduce body fat as well as protect against
chronic diseases associated with obesity. The (WHO), with Health 2020, is engaging all
Countries to develop an efficient approach in order to resolve health diseases. The aim of this
review is to discuss on obesity: epidemiology etiology, different methods to measure it, the role
of physical activity and governments to solve it. Additional research may foster understanding
about how and what sport to can help promote energy balance and healthy body weight.
Moreover, a new pharmacological target to fight obesity and its associated diseases are
represented by Endocannabinoid system.

Key words: Obesity, overweight, sport, weight loss, pharmacology, Physical activity

Introduction

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Obesity is and has been one of the most important health problems in the U.S. and in many
other countries. There is considerable evidence that links obesity with certain diseases of the
cardiovascular, endocrine, neurological system and diabetes (Mazzeo et al 2010). It is a
medical condition which occur when the body mass index is superior or equal to 30 kg of body
weight/m2 of height. It is characterized by the accumulation of excess fat that can lead
cardiovascular dysfunction, diabetes mellitus type 2, disorders of the osteoarticular system,
stroke, metabolic syndrome and cancer (Berthoud 2005; Must et al. 1999 ). Obesity is caused
by a combination of excessive food intake, lack of physical activity and genetic predisposition.
The WHO talks about “globesity” with the meaning of the global epidemic of overweight and
obesity. Obesity, in fact, is a problem for even more countries and for the entire society: from
the children to adults (Wilborn et al. 2005 ). Indeed, his incidence has increased in the last
twenty years, especially in developed societies (Mazzeo et al. 2016; Ogden et al. 2006; Flegal
et al. 2010). It was demonstrated that an adult affected by obesity is a result of childhood with
the same problem (Mason et al. 2008; World Health Organization Regional Office for Europe
2014).
The body of a obesity person is undergoing a premature aging process. An obese man can die
13 years before than a normal one (Fontaine et al. 2009) and the die risk increase of 30% every
15kg of overweight , due to the development of diseases (Sassi et al. 2010; Schmid et al. 2005).
The main reason why people gain weight is the change of their life style due to the technological
development (Lakdawalla et al. 2002). Additional reason is the consumption of too much
calories, which are increased, from 1980, about 12%. The entire society, introduce a surplus of
calories that real need for their bodies. They come, for example, from fizzy beverages, rich in
sugars or from fat food (Putnam et al. 2002; Mazzeo et al. 2010). Moreover, the wrong habit to
eat before the main meals is increased over the time (Nielsen et al. 2003) In addition, there are
genetics factors that are involved in this pathology (Finucane et al.2011).

Evaluation of people weight

People weight in adults varies with sex, height and age and there are various methods to measure
it. Body mass index (BMI) is a measure of body fat based on people weight in relation to their
height. It is divided by the square of his/her height (Messina et al. 2015). Even though it does
not measure body fat directly, it is inexpensive and easy-to-perform. The index includes six
weight conditions: from underweight to obesity III, as Table 1. A person with a BMI of 29.9 is

2
considered overweight but just with 0.01 point more (30 BMI), he is obese (Wilborn et al. 2005;
Orzano et al. 2004).

BMI Classification
Below 18.5 Underweight
18.5-24.9 Healthy weight
25.0 -29.9 Overweight
30 – 34.9 Obesity I
35 – 39.9 Obesity II
≥40 Obesity III

Table 1 Classification BMI.

The main problem linked to this index is his paradox. According to it, bodybuilders could have
the same BMI of a sedentary, fat, people. It, in fact, does not consider the fat quantity in the
person body and his musculature.

Figure 1 Different people with the same BMI.

A B
Muscle Mass 88.7 kg 69.5 Kg
Fat Mass 13.8 kg 25.8 Kg
Bone Mass 3.8 kg 2.8 Kg
Body Fat 13% 26.3 %
Total Weight 106.3 kg 98.1 Kg
Height 1.83 m 1.76 m

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 Table 2 Data of subject A and B

As you can see in Figure 1 and in Table 2, although the fat mass of person A is smaller than
subject B and the first one has a greater weight, they have the same BMI (31.7) which indicates
that both are affected by obesity (De Lorenzo et al. 2001)

Tests to diagnose obesity could be

- Waist circumference, Sagittal Diameter and Waist-To-Hip Ratio. They are
measurements for estimating the amount of fat mass deposited under the skin and inside
the abdominal cavity;
- Skinfolder Caliper which measures only the fat under the skin;
- Water Displacement Tests – Fat floats. This test consists in submerging a person
in water and calculating the volume of the displaced water from the weight of the
displaced water;
- Electrical Measurements that calculates the percentage of body fat by measuring the
difference electrical characteristics of fat and other body tissues;
- Blood test. This is the most common test recommended by physicians. Thanks to it, it
is possible to know how many fat there is in the blood and if a person suffers from
disorders, such as thyroid disorder;
- Plicometry is a technique that, through a device called plicometer, evaluates the
thickness of cutaneous plicae or folds (Rona et al. 2006). It is based on the relationship
between the subcutaneous adipose tissue and thin body mass;
- Densitometry, which is another technique that observes how thin tissues absorb,
determined electromagnetic waves in comparison with fat tissues;

Etiology

Obesity be determined by different factors such as genetics (Hamilton et al 2007; Messina et

al. 2015), but the main is the lack of physical activity, which is linked to an energy imbalance.
People, in fact, intake too much food they need causing a weight gain. Moreover, an unhealthy
diet in which there are a high consumption of sugar, fat and salt and low intaking of minerals,
vitamins and other micronutrients can lead to weight gain (Mazzeo et al. 2016). Furthermore,
the lack of exercise and the change of environmental lead people to spend time indoor, in front

4
of their devices. The preference to stay at own home is due to the fear of crime. Nevertheless,
leisure activities are changed: people, in fact, do less manual actions and even more sedentary
activities (Fontaine et al. 2003).
In addition, despite the fact genetic factors are rare to determine obesity, some people are
predisposed to obesity. They, indeed, suffer from genetical disorders such as Prader –Willi
syndrome and Bardet-Biedl syndrome.
Nevertheless, there are some hormones, insulin, leptin, neuropeptide Y, cortisol, ghrelin,
norepinephrine, serotonin, inteleukin-6 TNF and other pepetides involved in obesity (Messina
et al. 2015).
Orexyn, for example, is involved in the above-mentioned illness (Messina et al. 2015). It is a
neurotransmitter, which regulates the sleep-wakefulness and appetite (Date et al. 1999; Tao et
al. 2006). The distribution of orexin neurons and their receptors explains how they are involved
in numerous physiological processes, including the modulation of the sleep, the arousal and of
the energy expenditure, suggesting an important role in development of obesity (Tsujino,
Sakurai 2009; Hara et al. 2001; Kotz 2006). Obesity is associated with decreased levels of
orexin (Bronský J 2007). Orexin system regulates and consolidates sleep/ wake patterns.
Narcoleptic patients, with a lack orexin, have altered sleep patterns, highly fragmented sleep
and elevated body mass index (Kok et al. 2002). This shows how important is the orexin in
maintaining normal sleep/wake patterns and energy homeostasis.

Associated diseases

Fat accumulation starts during childhood. At beginning, children are "physiologically"

overweight (Mazzeo et al. 2010) . Later, the fat mass decreases up to 5 years and goes back up
to 10 years (James et al. 2006). In the puberty, there is a different fat distribution between male
and female: with a decreasing in the first one and an increasing in the second.
As regard fatty tissue, important changes occur in adipocytes which are involved in hyperplasia
and hypertrophy processes according to age. However, in obese child the increase in the number
of adipocytes is higher than normal person (Korth et al. 2007; Kaur et al. 2003).
Obesity means not only not to be able in performing daily activities but it is a risky condition
health due to the illnesses linked to it (Table 3)

5
 Cardiovascular congestive heart failure, enlarged heart and its
associated arrhythmias, dizziness, varicose veins,
pulmonary embolism
Hypertension lipidemic imbalance, the increase in triglycerides
and total cholesterolemia
Type 2 Diabetes and some cancers breast (postmenopausal), colon, endometrial,
ovary, cervical and gall bladder cancer in women
and colon, rectum and prostate cancers in men
Musculoskeletal Osteoarthritis
Hyperuricemia (which predisposes to gout) immobility, osteoarthritis, low back pain
Endocrine disease polycystic ovarian syndrome (PCOS), menstrual
disorders, and infertility
Gastrointestinal - gastroesophageal reflux fatty liver disease, cholelithiasis (gallstones),
disease (GERD) hernia, and colorectal cancer
Renal and genitourinary problems erectile dysfunction , urinary incontinence,
chronic renal failure, hypogonadism (male),
breast cancer (female), uterine cancer (female),
stillbirthbreast cancer (female), uterine cancer
(female), stillbirth
Neurologic stroke, meralgia paresthetica, headache, carpal
tunnel syndrome, dementia, idiopathic
intracranial hypertension.
Respiratory disorders obstructive sleep apnea, obesity hypoventilation
syndrome, asthma

Table 3- Illness linked to obesity

In order to psychological disease, may occur depression, low self-esteem, body dysmorphic
disorder, social stigmatization, really dangerous especially among in children and adolescents
(Dehghan et al. 2005).

Spread of the gain weight

In 46 European Countries on 51, more than 50% people are affected by overweight and more
than 20% by obesity (Altavilla et al. 2014). In particular, Hungary, Czech Republic, Greece,
The UK and Luxemburg show higher levels of percentage compared to Italy, Sweden, The
Netherlands, Austria and France ( In European countries, a range of 16-20% of death it was
caused by the above mentioned disease while in the United States at least 300.00 deaths every
year is due to this health condition (Ogden et al. 2006).
Those diseases depend on the level on various factors.
As regard the level of education, it is showed that his increasing leads the decreasing of chances
to get sick. In Europe, it is estimated that 26% of obese men and 50% of obese women is due
to the low education (James et al. 2006).

6
As concern the unhealthy life style, it is reported that In Italy, Denmark, France, The
Netherlands, Norway, Switzerland, Sweden and Great Britain, 60-100% of weight gain is due
to the excessive ingestion of food is rather than the lack of exercise (World Health Organization
Regional Office for Europe. 2014).
The prevalence of overweight among children younger than 16 years is between 10% and 20%
in the European Region, with rates higher among children in southern Europe. Their dietary
habits are not optimal for health. They, in fact, intake low quantities of fruits and vegetable and
too much sweetened beverages. Moreover, the level of physical activity decreases during
adolescence and in particular among the girls. The social and economic environment in which
adolescents grow up often determines their behavior (Weinsier et al. 1998). It is showed that a
premature approach to sex, alcohol and prohibited substances expose the adolescents not only
to direct health risks but depressive disorders and eating disorders
Obesity increase with the age. Even though men are more overweight than women (42.6%
against 32.1%), higher percentage of those last one are morbidly obese than men (2.7% against
0.9% respectively).
Furthermore, people of difference ethnicity have difference predisposition to obesity. Women
of minority ethnic group have higher levels of central obesity compared to the others. In
particular, Black African, Black Caribbean and Pakistani female are more affected by obesity,
respectively with 38.5%, 32.1% and 28.1%, than 23.2% of the general population. On the
contrary, Chinese women have the lowest level of obesity with only 7.6% (Harvey 2002; Stubbs
2004). Regarding the men, obesity among general population is 22.7%. The lowest level is
recorded among Bangladeshi followed by Chinese people (5.8% and 6%), while the highest
level (22.7%) is reported on Black Carribean men.

Economic cost and outlook for action

There are direct medical costs linked to the obesity (Hammond Ross and Ruth Levine 2010). It
is estimated that only in 2006 The UK spent 3.23 billion pounds, that is 5% of the National
Health System (Allender and Rayner 2007). Similar situation is found in The Netherlands where
the above-mentioned costs is 4% of the NHS, while in The USA are increasing. They, in 2000,
were between 5 and 7% but in 2008 between 9-10% (Wolf and Colditz 1998). China recorded
in 2003 a 3.7% of expenditure while Switzerland, in 2002, 3.5% (Zhao et al.2008).
In addition, it is shown that 54-69 aged people who are affected by obesity with a BMI range
of 30-35 cause an increasing of expenditure of 25% compared to normal weight. Moreover,
7
when there is a BMI range 35-40 the costs increase over 50% and reach at 100% in sever obese
with a BMI super to 40 (Andreyeva et al. 2004).
Since the last decades of the last millennium has shown an increasing worldwide interest in the
issue of health. In September 2012, at the session of the WHO Regional Committee for Europe,
it was approved by 53 European Countries, an important document entitled Health 2020. Its
aim is improve health and reduce health inequalities. The document is based on the awareness
that good health leads to the benefits of all sectors and the whole of society. It, in fact, is
essential for economic and social development.
“The health sector is responsible for: developing and implementing national and subnational
health strategies; setting health goals and targets for improving health; assessing how the
policies of other sectors affect health; delivering high quality and effective health care services;
and ensuring core public health functions. It also has to consider how its health policy decisions
affect other sectors and stakeholders.”
According to the document, fair access to education, good work conditions, housing and income
support health, like a virtuous process (Fig. 2).

Education

Good Health Good job

Housing Income

Figure 2 Benefits for all sectors

In contrast, the growth of chronic disease and mental disorders, the lack of social cohesion, the
environmental dangers and financial uncertainties make improving health even more difficult
and threaten the sustainability of health and welfare systems. A large burden of disease in
European Countries, particularly chronic non-communicable disease, severely affects labor
markets and productivity. Diseases lead to disparities in employment opportunities and wages,
affect productivity at work and increase sick leave and the demand for welfare benefits (Zhao
et al.2008).
8
Moreover, health costs represent a great challenge to governments due to the fact that it has
grown more than economic growth in many Countries in where the health share of government
budgets is larger than ever, and health care costs have grown faster than Gross Domestic
Products (Hammond and Levine 2010). However, for at least some of these countries, data show
a lack of correlation between health expenditure and health outcome (Fig. 3)

health
expenditure

health
outcome

Figure 3 Lack of correlation between health expenditure and health outcome

Health 2020 suggests, with the aim to contain costs, spending more resources in health
promotion and disease prevention. In this contest, media plays an important role to promote
healthier behavior by informing people about the risks of obesity and other causes of disease.
Moreover, in order to remove the adverse effects of illness and inequalities on every sectors,
European governments should have to engage in intersectional approaches for health, including
economic, social and political benefits of good health.
In particular, it is important to create new skills in managing conflicts of interest and finding
new ways of tackling intractable complex problems. Together with Member States, WHO has
a special responsibility to exercise such leadership and to support health ministries in achieving
their goals.
Moreover, “Empowering people, citizens, consumers and patients is critical for improving
health outcomes, health system performance and patient satisfaction. The voice of civil society,
including individuals and patient organizations, youth organizations and senior citizens is
essential to draw attention to health-damaging environments, lifestyles or products and to gaps
in the quality and provision of health care. It is also critical for generating new ideas.”
According to Health 2020, even though children are exposed to marketing pressure to intake
foods high in saturated fat, trans-fatty acids, free sugar or salt, the preventive actions are simple

9
and cheap. It need, in fact, promoting the awareness of the benefit of a physical activity: for
example, through urban design and planning the school day, school-based health literacy
programmers; peer-to-peer education; and the development of youth organizations (WHO.
Health 2020, 2013).

Physical activity

Physical activity describe all movement produced by skeletal muscles which increases energy
expenditure, whether exercise or sport (Altavilla et al. 2014, Pizzuto et al, 2016, Raiola et al,
2016). Physical activity includes cardiorespiratory fitness, body composition, muscle strength
and flexibility. Exercise is a subset of physical activity that is planned, structured, repetitive,
and purposeful in the sense that improvement or maintenance of physical fitness is the objective
(Mazzeo et al 2015). A important interrelationship exists between the total dose of activity (total
amount of energy expended in physical activity) and the intensity (the rate of energy
expenditure during such activity) at which the activity is performed. Intensity reflects the rate
of energy expenditure during exercise and is usually expressed in metabolic equivalents or
METs, where 1 MET equals the resting metabolic rate of 3.5 mL O2 · kg-1 min-1(Altavilla et
al.2014). Relative intensity refers to the percent of aerobic power utilized during exercise and
is expressed as percent of maximal heart rate or percent of O2max. In relative terms, this
intensity is considered light for a 20-year-old healthy person but represents a vigorous intensity
for an 80-year-old person. At present daily participation in moderate and vigorous physical
activities is low, and activity decreases with increasing age (Mazzeo et al 2016) .
The role of sport and physical activity in children, for optimising bone mass and reducing
obesity and insulin resistance, people with cardiac disease and older people, merit special
attention. Effective strategies exist for managing obesity yet are rarely used by physicians . For
general health benefits 30 minutes of at least moderate intensity physical activity is
recommended on 5 or more days of the week (Mazzeo et al 2016) . This can be achieved by
doing all the activity in one session or through several shorter bouts of activity of 10 minutes
or more. The activity can be structured sport or lifestyle activity (part of everyday life e.g.
climbing stairs, brisk walking) or combination of both. To prevent obesity 45-60 minutes of
moderate intensity physical activity each day may be needed. To maintain weight loss 60-90
minutes of moderate intensity physical activity each day may be required in people who have
been obese and have lost weight. Frequent and regular aerobic exercise has been shown to help

10
prevent or treat serious and life-threatening chronic conditions such as high blood pressure,
heart disease, Type 2 diabetes, insomnia, depression and obesity (Diehl and Choi 2008)
Physical activity carried out regularly and with at least thirty minutes a day, combined with an
adequate diet, determines, in a medium-long period, an increase of energy and thus a
corresponding decrease adiposity (Mazzeo et al 2010).

Conclusions

Adults, sedentary people may suffer from obesity and may develop chronic diseases such as
coronary heart disease, hypertension, hypercholesterolemia, cancer, musculoskeletal disorders
(Finucane et al.; Orzano and Scott 2004; Raiola et al. 2015).
Moreover, some population are more predisposed to obesity such as: Black African and
Pakistani female and Black Caribbean - male and female- (Orzano AJ, Scott JG 2004). There
are lots instrument to diagnose obesity but the most useful is the Body Mass Index. An exercise
training, an healthy life style and an efficient health system may resolve the problem of gain
weight (Altavilla et al, 2014, Guetano et al, 2015). It is important combine the above mentioned
the suggestions to have a real change (Hamilton et al. 2007). The government play an important
role to impose new life style models in which people have to spent more time outdoor, doing
physical exercises and eating more fruits and vegetable rather than fat, salted foods (Kotz CM
2006). Moreover, for pharmacological therapy the endocannabinoid system represent a new
pharmacological target for obesity treatment. The endocannabinoid system, which is well
known for its contributions in certain mental processes such as relaxation, improvement of pain
and anxiety, and sedation initiation, has been recently reported to play an essential role in
regulating appetite and metabolism to maintain energy balance, leading to the acceptance that
endocannabinoid system is closely related to obesity (Hu Zhu and Huang 2009).
Nevertheless, governments have better to spend the health expenditure in order to improve other
society sectors and offer to the people best conditions to live and stay healthy

Corresponding author :
Filomena Mazzeo,MD,PhD
Assistant Professor in Pharmacology and Clinical Toxicology
Department of Science and Tecnology
University of Naples "Parthenope"
Phone : 0039 0815476648
e-mail: filomena.mazzeo@uniparthenope.it

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