Management of Body Composition

All people—the fat, the thin, and the in between—can benefit by adopting attitudes and behaviors that over time should promote the body composition appropriate to each individual’s genetic makeup and contribute to true wellness.

Role in Wellness

http://evolve.elsevier.com/Grodner/foundations/ Nutrition Concepts Online

What does weight or fatness mean to us as members of our contemporary culture? We step on the scale frequently, we read the numbers, and we often seem to get a message that extends beyond the simple mass of heaviness of our bodies. What message does the scale deliver? For some members of our culture, the figures on the scale convey something about their physical health. For others, the scale measures attractiveness. Sometimes it measures a sense of empowerment, of being in control of our lives. How can one simple assessment convey so many powerful interpretations? This chapter explores the meanings of weight or fatness in our contemporary culture and challenges these meanings and how they relate to wellness.

Because it is body fat that is really the issue, our focus is on fat rather than on weight. In addition, we use the approach of management of body composition; specifically body fat levels, rather than achievement of ideal body fatness. In this context, management is defined as the use of available resources to achieve a predetermined goal. This definition recognizes that individuals differ in the resources available to them and in the goals they set.

Consideration of the dimensions of health helps emphasize that managing body composition is more than just counting calories. Managing body composition levels by decreasing or increasing body fat or lean body mass is, if appropriate, an aspect of the physical dimension of health. Adequate levels of body fat allow the body to function most efficiently. The intellectual dimension of health provides the skills to understand and critique the role of society in molding our attitudes toward the shapes of our bodies. Regardless of body size, our emotional health depends on our developing positive self-esteem. The social dimension of health may not be affected by body fat levels, although those at either extreme of body size may need to develop a circle of friends and family who accept their size differences. The spiritual dimension of health is sometimes tested as a belief in a higher being, providing support for some individuals struggling with behavior changes related to food consumption.

Body Composition, Body Image, and Culture

Most of us weigh ourselves regularly and have a good idea of our current weight. The figure on the scale, however, does not always agree with how fat we feel. Figure 10-1 shows an example of the type of instrument that investigators use to assess differences between actual, perceived, and preferred body size. The investigator instructs the subjects to mark the figure that is most like the way they feel at that time, as well as the figure that they consider ideal for themselves. When these figures are compared with an objective assessment, regardless of their actual size, the subjects usually have greatly overestimated their size.

FIG 10-1 An example of a figure rating scale. (Modified from Stunkard AJ, Sorensen T, Schulsinger F: Use of the Danish adoption register for the study of obesity and thinness. In Kety SS: *Genetics of neurological and psychiatric disorders, ARNMD series,* vol 60, New York, 1983, Raven Press.)

Body Preferences: Gender Concerns

Investigators also use figure rating scales to determine how men and women differ in size preferences; they ask you which figure is most like how you would like to be, which is most like how you currently are, and which you think is most attractive to the opposite sex. Ideally, the answers to these three questions would be closely clustered, indicating that you are fairly satisfied with your size. For men, that is usually the case. Women, however, on average consider themselves much fatter than they think is ideal. Originally it was assumed that the women’s dissatisfaction represented a desire to appear more slender and, therefore, more attractive to men. Usually, however, women’s personal ideal is thinner than the figure they think men would choose, challenging the assumption that women want to be thin to attract men. An alternative interpretation is that both men and women interpret a slender body as evidence of being in control of one’s life.²

Body Acceptance: A Key to Wellness

Why is body image important? A negative body image may affect how we feel about ourselves generally: body image tends to become self-image. Furthermore, a negative body image may influence our health behaviors. We may feel defeated that because our bodies are so bad, it is not worth working hard to improve our health. At other times we may feel drawn to various kinds of risky behaviors in a frantic attempt to make our bodies more acceptable. We may strive mightily to meet the societal standards of attractiveness and thinness, but, given our individual genetic makeup, we cannot all succeed. Although humans have an awesome potential for growth and development, there are limits to the changes we can make and sustain in our body size and shape.²

If we have a healthy and positive body image, we evaluate various aspects of our bodies fairly realistically, finding some characteristics positive and others less so. Those we consider weak or unattractive, we accept in a dispassionate way, much the same way that we accept that we don’t all have beautiful singing voices or the ability to throw a great curveball. We understand that our bodies have multiple aspects, that there is more to our bodies than their size and shape. Our healthy body image is influenced by our awareness of how our bodies function and how they look. This image affects and is affected by socio-demographic factors. Body image satisfaction may be related to the degree of overweight and to psychologic distress represented by depression and low self-esteem.³ Understanding and accepting what we can and cannot expect to achieve in pursuit of the ideal body is a key to wellness. Only with this understanding can we establish goals to guide our behaviors toward health (see the Social Issues box, Dealing With Our Own Prejudices).

Social Issues

Dealing With Our Own Prejudices

We live in a world in which fat intolerance or fat phobia (fear of fat) is the last socially acceptable prejudice. “Fatism” even seems to have similarities with racism. As a society, we are committed to self-improvement. Consequently, it may feel wrong to question the directive that all those who deviate from the ideal size and shape should dedicate themselves to rectifying the situation. Our fat intolerance may be motivated by the best intentions to be helpful to ourselves and to others, but like all prejudices, it diminishes the people to whom it is applied.

This prejudice is especially problematic when it exists among health professionals. Obese people often report they feel degraded by their health care encounters and therefore avoid seeking medical help. The traditional medical model holds the patient responsible for the existence of a health problem; this moralistic philosophy tends to justify blaming the patient for choosing to be fat or thin. Although this prejudice could be expected to interfere with their effectiveness, health professionals seem to possess high levels of fat intolerance. Consider these facts from National Association to Advance Fat Acceptance (NAAFA):

Medical Professionals

In a study of 400 doctors, the following was found:

• One out of three listed obesity as a condition to which they respond negatively, ranked behind only drug addiction, alcoholism, and mental illness.

• Obesity was associated with noncompliance, hostility, dishonesty, and poor hygiene.

• Self-report studies show that doctors view obese patients as lazy, lacking in self-control, noncompliant, unintelligent, weak-willed, and dishonest.

• Psychologists ascribe more pathology, more negative and severe symptoms, and worse prognosis to obese patients compared with thinner patients presenting identical psychological profiles.

In a survey of 2449 overweight and obese women, the following was found:

• 69% experienced bias from doctors.

• 52% experienced recurring incidents of bias.

In one survey of nurses, the following was found:

• 31% said they would prefer not to care for obese patients.

• 24% said that obese patients “repulsed them.”

• 12% said they would prefer not to touch obese patients.

Consequences

• Avoidance of proper care

• Reluctant to seek medical care

• Cancellation or delay of medical appointments

• Delay important preventative health care

• Doctors seeing overweight patients:

Spend less time with patient

Engage in less discussion

Show reluctance to perform preventive health screenings (i.e., pelvic exams, cancer screenings, mammograms)

Do less intervention

• Appropriate-sized medical equipment not available:

What about you? Have you been successful in questioning and replacing your own prejudices? Are you able to accept yourself and your body? As a future health professional, are you prepared to empower your patients to work toward total wellness, including the Health At Every Size (HAES) philosophy and habits?

Data from NAAFA: Healthcare, 2009. Accessed February 23, 2010, from www.naafaonline.com/dev2/the_issues/health.html.

Management of Body Fat Composition

If we say that individuals must choose their own values and goals, it is impossible to state one goal for everyone. Nevertheless, we can identify some probable commonalities. Surely most of us would define a goal of maximizing the quality and length of our lives. We probably can go further and say that our goal is to achieve the best possible health, including emotional, social, intellectual, physical, and spiritual aspects. This chapter proceeds on the premise that we can agree on some version of this goal. Most of us would also agree that too little and too much fat are likely to compromise physical health. In addition, we assume that the relationship between fatness and well-being is limited. That is, being slender does not guarantee happiness and health in all its aspects, nor is being heavy a sentence of unhappiness and illness.

Association of Body Fatness with Health

Physical Health

Most of our evidence of the association between fatness and physical health comes from epidemiologic studies. Epidemiologic research investigates the distribution of disease in a population and seeks to explain associations between causative factors and the disease. This type of research usually involves thousands of subjects and may be longitudinal (i.e., involving observations over a number of years). Because it is not practical to measure fatness in these large studies, weight is usually measured instead. Weight is most meaningful when considered in relationship to height. A convenient way to determine fatness is to calculate body mass index (BMI), a value derived by dividing one’s weight in kilograms by the square of one’s height in meters (Table 10-1). This formula for BMI results in a value that correlates well with body fatness.

TABLE 10-1

BODY MASS INDEX TABLE

NORMAL							OVERWEIGHT					OBESE
BMI	19	20	21	22	23	24	25	26	27	28	29	30	31	32	33	34	35
Height (Inches)	Body Weight (Pounds)
58	91	96	100	105	110	115	119	124	129	134	138	143	148	153	158	162	167
59	94	99	104	109	114	119	124	128	133	138	143	148	153	158	163	168	173
60	97	102	107	112	118	123	128	133	138	143	148	153	158	163	168	174	179
61	100	106	111	116	122	127	132	137	143	148	153	158	164	169	174	180	185
62	104	109	115	120	126	131	136	142	147	153	158	164	169	175	180	186	191
63	107	113	118	124	130	135	141	146	152	158	163	169	175	180	186	191	197
64	110	116	122	128	134	140	145	151	157	163	169	174	180	186	192	197	204
65	114	120	126	132	138	144	150	156	162	168	174	180	186	192	198	204	210
66	118	124	130	136	142	148	155	161	167	173	179	186	192	198	204	210	216
67	121	127	134	140	146	153	159	166	172	178	185	191	198	204	211	217	223
68	125	131	138	144	151	158	164	171	177	184	190	197	203	210	216	223	230
69	128	135	142	149	155	162	169	176	182	189	196	203	209	216	223	230	236
70	132	139	146	153	160	167	174	181	188	195	202	209	216	222	229	236	243
71	135	143	150	157	165	172	179	186	193	200	208	215	222	229	236	243	250
72	140	147	154	162	169	177	184	191	199	206	213	221	228	235	242	250	258
73	144	151	159	166	174	182	189	197	204	212	219	227	235	242	250	257	265
74	148	155	163	171	179	186	194	202	210	218	225	233	241	249	256	264	272
75	152	160	168	176	184	192	200	208	216	224	232	240	248	256	264	272	279
76	156	164	172	180	189	197	205	213	221	230	238	246	254	263	271	279	287

Data from Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: The evidence report. From National Institutes of Health: Aim for a healthy weight, NIH Pub. No. 05-5213, Bethesda, Md, 2005 (August), U.S. Department of Health and Human Services.

If we were to plot the findings of epidemiologic studies of the association of BMI and the risk of certain diseases or mortality from all causes, we would usually produce a U-shaped curve such as that shown in Figure 10-2.⁴ This curve means that individuals at both extremes of fatness—those very thin and those very fat—are at increased risk. Those at a more moderate fatness level have the lowest risk for the four leading causes of death in the United States: heart disease, some types of cancer, stroke, and diabetes. It is a surprise to many people that the low end of the fatness range, or underweight, shows an increased risk, which provides strong evidence that one can be too thin.

FIG 10-2 U-shaped relationship between BMI to excess mortality in adults. Relative risk was defined as 1 for adults with BMIs between 20 and 25. (From Stipanuk MH: *Biochemical, physiological, & molecular aspects of human nutrition,* Philadelphia, 2006, Saunders.)

It is possible that the lowest BMI in these types of curves reflects low levels not of fat but of the lean body components.⁴ The higher risks at the low BMI levels probably reflect some degree of body wasting, including lean body mass, possibly caused by smoking or the effects of disease. To understand the effect of fat on mortality, we need to measure body composition (fat and lean) and not rely on weight alone. Although the factors contributing to this increased risk of extremely low weight are not completely clear, they are thought to differ from the factors associated with increased risk of heavy individuals.

Physically disabled individuals are at greater risk for obesity because of physical inactivity, muscle atrophy, and metabolic energy alterations. Strategies implemented to prevent weight gain support all dimensions of health.