By Dr. Randolf Dylan Y. Cabahug and Dr. Gorgonia P. Panilagao
Last October 2023, recommendations were developed on the diagnosis of overweight and obesity and on the screening for obesity-related risk factors and health conditions among adults. The guidelines followed the International Classification of Disease (ICD) Definition of obesity, defining it as a chronic, relapsing and progressive, multifactorial disease. The prevalence of obesity among Filipino adults continues to rise, presenting more Filipinos with unique risk factors and heightened predisposition for select disease.
The guidelines recommend the use of the Asia-Pacific criteria cut off for BMI rather than the WHO criteria; that is, a BMI of >23.0 for overweight patients, and >25.0 for obese patients. This has not been without controversy, however. BMI is only an estimate of body fat, and its validity may be challenged by the presence of metabolically healthy obesity (in which metabolic complications are absent) and the obesity paradox (lower mortality rate for overweight or obese people within certain subpopulation). BMI alone may also not accurately diagnose obesity since it considers total body weight and not just adiposity. Though BMI is the best screening measure we have, it is likely not sufficient or ideal for diagnosis. Therefore, the current guidelines suggest the use of waist circumference (>90cm in men and >80cm in women) and waist-to-hip ratio (>1 in men and >0.85 in women) in addition to BMI to diagnose obesity.
Is obesity a case of nature or nurture? By nature, we refer to the contribution of genetic influences on obesity. By nurture, on the other hand, we have the contribution of environmental influences on obesity – the ‘obesogenic’ modern environment. This includes the increases in the availability of processed and high calorie foods, the total number of food outlets, portion sizes, food advertising, large supermarkets, and sedentary leisure time, as well as reduced barriers to food trade. More likely, it’s both nature and nurture, in which individuals who inherit a more avid appetite are more likely to overeat in response to the opportunities offered by the current environment, and to develop obesity.
Aside from the diagnosis of obesity, the guidelines recommend screening for the multisystemic complications:
Hypothyroidism, using thyroid-stimulating hormone among adults aged <70 years at initial visit
Polycystic ovarian syndrome, using the Rotterdam criteria
Dysglycemia, using the 75gm OGTT least once a year
Dyslipidemia, using a fasting lipid profile
Hypertension, using a non-invasive blood pressure measurement with an appropriately sized cuff at least once a year
Non-alcoholic fatty liver disease, using liver ultrasound
Obstructive sleep apnea, using the STOP-BANG questionnaire once a year
Depression, using the Patient Health Questionnaire-9 tool every 6 months
Osteoarthritis, using the American College of Rheumatology clinical classification criteria at every visit; and use of obesogenic medications for other health conditions at every visit.
How about pharmacotherapy for obesity? The local guidelines actually do not present a consensus on pharmacologic interventions for obesity. In this case, we may refer to the Asia-Oceania Association for the Study of Obesity, and their consensus statement on consensus on care and management of obesity in Southeast Asia. In this consensus, lifestyle modifications are still the first choice of treatment, but use of pharmacotherapy for adults with a BMI of 25–26.9 kg/m2 may be considered on a case-by-case basis to help ameliorate obesity-related complications. Use of pharmacotherapy in these individuals should only be carried out by clinicians experienced in obesity medicine, with close monitoring. If the clinician opts for pharmacotherapy, orlistat, phentermine and liraglutide 3mg are the only anti-obesity medications available in our country.
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