Central obesity in adult patients with optimal weight in primary health care

Uvod. Pojedinci sa normalnom telesnom težinom i povećanim obimom struka imaju 20% veći rizik za nastanak oboljenja od lica sa normalnom telesnom težinom i obimom struka. Cilj rada. Ispitati stepen uhranjenosti i učestalost centralne gojaznosti kod normalno uhranjenih odraslih pacijenata Doma zdravlja Novi Sad i da li postoje razlike u odnosu na pol i godine starosti. Metod. Retrospektivna analiza antropometrijskih podataka, evidentiranih u elektronskom zdravstvenom kartonu 39.751 odraslog pacijenta. Rezultati. Analizirani su podaci 23.264 žena i 16.487 muškaraca. Prosečna starost ispitanika iznosila je 53,8 godina (SD 15,419). Prosečna vrednost indeksa telesne mase – ITM iznosila je 26,5 kg/m2 (SD 4,73), a obima struka 90,1 cm (SD 14,25001). Normalno uhranjenih ispitanika muškog pola bilo je 28,8% i ženskog pola 46,1%. Postoji značajna statistička razlika u stepenu uhranjenosti u odnosu na pol i godine starosti (p<0,005). Centralnu gojaznost imalo je 21,2% normalno uhranjenih osoba muškog pola i 37,0% ženskog pola. U grupi normalno uhranjenih pacijenata sa centralnom gojaznošću, 79,7% činile su osobe ženskog pola a 20,3% muškog pola. U ovoj grupi pacijenata centralna gojaznost je najzastupljenija u starosnoj grupi od 60 do 69 godina. Postoji statistička značajna razlika u odnosu na pol i starosnu grupu (p<0,005). Zaključak. Imajući u vidu da je više od trećine normalno uhranjenih ispitanika imalo centralnu gojaznost, radi utvrđivanja rizika za nastanak hroničnih masovnih nezaraznih bolesti povezanih sa centralnom gojaznošću, pored određivanja indeksa telesne mase-ITM neophodno je i rutinsko merenje obima struka. Ključne reči. uhranjenost, gojaznost, obim struka, gojaznost u normalnoj telesnoj masi, ITM. Abstract


Introduction
Overweight and obesity are defined as an unusual or excessive accumulation of fats, which may endanger one`s health, and due to the worldwide spread of the disease it has become a global problem 1.2 .
According to the WHO (World Health Organisation) data from 1975, the number of obese people in the world almost tripled. In 2016 more than 1.9 billion people, aged 18 and older were overweight, and among them 650 millions were obese 3 .
According to the WHO criteria, obesity is defined as a BMI ≥ 30 kg/m 2 and it goes for both genders and all age groups. Although this method is the most common in clinical practice, it has its limitations because it doesn`t take into account the same percentages of fats in different individuals. So, in order to define and classify obesity other parameters should be considered, such as waist circumference (WC), hip to waist ratio, or the percentage of body fat 3,4 . Measuring waist circumference in primary health care (PHC) is easy and it is a useful clinical surrogate marker for the evaluation of the abdominal fat. It may be used for the evaluation of the cardiometabolic risk related to the distribution of body fat 5 .
Overweight and obesity are the main risk factors for many non-communicable diseases [6][7][8] . It is important to stress the risk of cardiometabolic multimorbidity increases with the increase of BMI; it`s twice as high in the overweight patients to more than ten times higher in excessively obese patients, when compared to people with optimal weight 9 .
From the clinical aspect, according to the IDF (International Diabetes Federation), the waist circumference (≥ 94 cm for men and ≥80 cm for women, in Europian countries) which is defined in relation to ethnicity, abdominal, central obesity is gaining a place of a necessary parameter essential for the diagnosis of metabolic syndrome. The main diagnostic components of the metabolic syndrome, besides waist circumference, are triglycerides levels > 1.7 mmol/l; HDL levels < 1.03 mmol/l for men and < 1.29 mmol/l for women; SBP values ≥ 130 mmHg and/or DBP ≥ 85 mmHg or previous antihypertensive therapy; glucose levels ≥ 5.6 mmol/l or previously diagnosed type 2 diabetes. Using the internationally accepted waist circumference threshold values, it was found the metabolic syndrome doubles the risk of cardiovascular diseases 10,11 . Also, there is a strong correlation between central obesity, hypertension, cardiovascular diseases, hyperlipoproteinemia, type 2 diabetes, port vein thrombosis, and breast cancer [12][13][14][15][16] .
higher risk of getting ill as compared with individuals with the optimal weight and waist circumference 23 . The study of Sun et al. in 2019 pointed that menopausal women with abdominal obesity and optimal body weight had a higher risk of death of all causes, cardiovascular diseases, and death from cancer, as compared to women with optimal body weight but without abdominal obesity 24 .

Objective
We aimed at investigating the nutrition level and the prevalence of central obesity in the PHC "Novi Sad" patients with optimal body weight and whether there was a difference in relation to gender and age.

Method
The retrospective analysis of the EHR database of the 39.751 adult patients of the PHC "Novi Sad". We took into account their body weight, height, BMI, and waist circumference. The anthropometric measurements of the patients (weight, height, waist circumference, BMI) are a part of daily activities in our PHC and all the data are safely stored in the patients` EHRs.
BMI was calculated to estimate the nutritional status (BMI = body weight/body height 2 , kg/m 2 ). The nutritional status was estimated using the WHO`s criteria: BMI < 18.5 kg/m 2 means a patient is underweight, BMI between 18.5-24.9 kg/m 2 means a patient has optimal weight, BMI between 25-29.9 kg/m 2 signifies pre-obesity, and BMI ≥ 30 kg/ m 2 means the patient is obese 1 . To estimate the presence of the central obesity we measured waist circumference, using the IDF metabolic syndrome criteria for the Europian area (waist circumference for men ≥ 94cm, women ≥ 80cm) 9 . The anthropometric measurements are used to screen for the underweight or overweight patients, but also to evaluate the nutritional status. Besides anthropometric measurements, lab tests, physical examinations, demographic data, the influence of the environment and the cultural factors should also be taken into account 25 .
To measure body weight, we used the medical scale with the measuring accuracy of 0.1kg. Body height was measured in the standing position, with the measuring accuracy of 0.1cm. Waist circumference was measured by using measuring tape with the measuring accuracy of 0.1cm, at the level of the mid-range between the lowest point of the rib cage and the top of the hip bone.
The gathered data were entered into the specifically designed database and analyzed using statistical package SPSS for Windows.
Waist circumference values ranged from minimal 35cm to a maximum of 170 cm, with an average value of 90.09cm (SD 14.25001). The presence of central obesity, with a waist circumference of ≥ 80 cm for women, and ≥ 94 cm for men, in relation to gender and age are shown in Table 2. Table 2. Central obesity in relation to gender and age In the population of the participants of both genders, with the optimal weight, central obesity was found in 4.977 (32.17%). The presence of central obesity, in relation to gender and age, among the participants with optimal weight is presented in Table 3. Table 3. Central obesity in optimal weight in relation to gender and age

Centralna gojaznost OS ≥80 cm ((Ž) i OS ≥94 cm (M)
Central obesity (WC ≥80 cm (F)  In the group of patients with optimal weight and central obesity, 79.7% were women and 20.3% were men. When compared to age, central obesity in participants with optimal weight was the most frequent in the 60-69 age group (Table 4).

Discussion
More than half of the adult patients from PHC Novi Sad were overweight, one fifth was obese, and less than twofifths had optimal weight. Unlike females, males were more likely to be overweight or obese. There was a significant statistical difference in nutritional status in relation to gender (p<0.005). The largest percentage of the underweight or those with optimal weight was found in the 18-29 age group. The largest percentage of the overweight was found in the 70-79 age group and the obese in the 60-69 age group. There was a significant statistical difference in nutritional status in relation to age (p<0.005). There was a smaller percentage of those with optimal weight, than those who were overweight, in our sample, when compared to the findings of the Health research of the Serbian inhabitants, from 2013 26 . The assessment of the Croatian authors, from 2003, was that 38.11% of the Croatian population was overweight and 20.34% was obese, which is along the lines of our research 27 .
Central obesity, according to the criteria, was found in 62% of the participants. Less than two-thirds of the females had a waist circumference of ≥ 80cm. In relation to age, central obesity was most frequent in the 60-79 age group. There was a statistically significant difference in the prevalence of central obesity, in relation to gender and age (p<0.005). The percentage of males with central obesity, in our sample, was higher than that of females when compared to the Health research of the Serbian inhabitants, from 2013. 26 When compared to the results of the Croatian research, from 2003, the percentage of our participants with central obesity was much higher, which can be attributed to different central obesity defining criteria (IDF vs. WHO criteria) 27 .
More than a fifth of males and a third of females with optimal weight had central obesity. In the study of Stokic E.J. et al. from 2002, the incidence of obesity in optimal body mass was 32.89% in females and 17.18% in males. Although quite similar, these parameters could not be compared because their study participants were the students of the fourth and fifth year of the Medical school, Novi Sad, and for the assessment of the visceral fat they used the percentage of the fat body mass calculated by using bioelectric impedance 28 .
In the group with optimal weight and central obesity, there was a statistically significant difference in relation to gender and age (p<0.005). Our data were consistent with data from 2017 and 2019 which also indicate the abdominal obesity was very frequent in PHCs, and more so in women than men 29,30 .

Conclusion
Bearing in mind that more than a third of the participants with optimal weight had central obesity, and in order to assess the risk of the non-communicable diseases connected to it, besides BMI it is necessary to measure waist circumference as well.
Our results also indicate it`s necessary to step up our preventive activities with our patients, so they could acquire healthy lifestyles and prevent obesity. We should be also intensifying our therapeutic approach to treating obesity and lowering the risk of the appearance of the consequent diseases.