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To the Editor: The association between obesity and cardiovascular disease is controversial and was not recognized as a major independent cardiovascular risk factor by the American Heart Association until 1998. One explanation could be the high degree of comorbidity and limitations in the clinical assessment of obese patients.1 A potentially better way to define obesity is by assessing body fat, in which obesity could be defined as greater than 25% body fat in men and greater than 35% in women.2 A practical alternative could be a combined assessment of the main anthropometric measures and the degree of physical activity or fitness (ergo-anthropometric classification), which allows identification of sedentary obese (or unfit-obese) individuals, a subgroup with greater cardiovascular risk and theoretically more body fat.
Evidence supporting the superiority of ergo-anthropometric assessment1 vs isolated anthropometric assessment includes the following:
These results support the validity of the new ergo-anthropometric classification,1 which includes assessment of waist circumference and physical fitness, in addition to BMI. It has the following advantages compared with the American National Heart, Lung, and Blood Institute classification: (1) the risk score it assigns is modified if lifestyle is sedentary or unfit; (2) it allows identification of sedentary-normal weight, active-overweight, active-obese, sedentary-overweight, and sedentary-obese subgroups who have an increased risk4,5; (3) it includes the waist-hip ratio in the abdominal obesity assessment because there is no consistent evidence for which of the main anthropometric measures is best10; and (4) it takes into consideration that underweight (BMI, <18.5 kg/m2) is an increased risk (especially in secondary prevention).
Recent reports on the obesity paradox (overweight-obese people with established cardiovascular disease have better prognosis compared with normal-weight patients)11 have led to doubts regarding the usefulness of anthropometric assessment and goal weight management in secondary prevention. However, unmeasured prognostic factors could be the main confounding mechanism that explains the obesity paradox.1