230 SECTION 3 Preventive medicine and public Health obesity counseling to physicians treating patients with a The importance of this perspective is in how it relates to body mass index(BMI)of 30 or greater(Table 19-1 prevailing societal responses. The treatment of drowning There is a potential liability, however, in cataloging obesity after it occurs is relatively rare and far from optimal. Many a disease. Diseases are states of aberrant body function to teaching children how to swim, to putting fences around generally amenable to medical treatments (e.g., pharmaco therapy, surgery). If obesity constitutes such an aberrant pools--to prevent drowning from occurring. Only when the state,it invites a focus on such treatments as bariatric surgery clear emphasis on environmental approaches to prevention and antiobesity drugs. The effectiveness of bariatric surgery fails does the treatment of drowning become germane, as a is well established and the pursuit of effective drugs for last resort weight management well justified, but a dedicated focus on hroughout most of human history, calories have been these approaches can and likely does distract attention and relatively scarce and often difficult to obtain, and physical divert resources from policies and programs that facilitate activity has been an unavoidable requirement for survival better use of feet and forks. In other words, by blaming Modern society has devised an environment in which physi obesity on a diseased state of the body, the potential to cal activity is scarce and often difficult to maintain, and calo- address the diseased state of the obesigenic(obesity-causing ries are unavoidable. Homo sapiens are endowed with no environment may be diminished native defenses against caloric excess and the tend An analogy well suited to clarify this perspective is dr toward "sedentariness The result is the modern obese ing. Drowning is a legitimate medical condition for trends In essence, the population is confronting an environ medical care is warranted and for which both diagnostic ment for which it is poorly suited and is succumbing to its codes and reimbursement are available. However, no one toxic effects. We are drowning in calories. This perspective mistakes the propensity to drown as an"aberrant state of might promote an emphasis on environmentally based the body. Rather, a perfectly normal and healthy body is approaches(policies and programs that facilitate healthful simply not suited to breathing under the water. Drowning eating and routine physical activity)to obesity prevention (or near-drowning) is recognized universally as the inevita- and control, even while establishing the medical legitimac ble outcome when a normal body spends too much time in of obesity as a condition deserving treatment( Box 19-3 an environment(underwater) to which it is poorly suited Nonmodifiable risk factors for obesity include low resting energy expenditure, genetic polymorphisms that predispose to weight gain and impede weight loss, and an ethnic heri- Table 19-1 CLassification of Weight Status Based on Body tage that increases the propensity for obesity. Modifiable risk Mass Index(BMD) factors relate principally to the quality and quantity of dietary intake and energy expenditure through exercise. Lean BMI* Classifcation body mass can be increased through exercise and thus also constitutes a modifiable risk factor. Insomnia increases obesity risk by several mechanisms, and thus impaired sleep is a potentially modifiable risk factor as wel The primary and secondary prevention of obesity prind 30-34.9 35-399 pally involve Stage Ill(severe)obesity terns. Secondary prevention includes screen means clinical assessment of weight and height(BMI)as well pressed as weight in kilograms divided by the square of the height in meters as waist circumference, and for children the plotting of BMI on appropriate growth charts. Box 19-3 Summary of Obesity Risk Factors and Prevention Secondary Prevention Screening: Assessing body mass index(BMI)and waist Resting energy expenditure/basal metabolic rate cren ce in clinical practice; plotting pediatric BMI or growth charts licit Physical activity promotion ww Possible use of pharmacotherapy Tertiary Prevention Sleep quality and quantity Bariatric surgery Pharmacotherapy Primary Prevention Dietary management and physical activity promotion as important Dietary management: improved quality, control of quantity dividuals.Tertiary prevention is for symptom o prevent them from becoming obese. Secondary prevention is for asymptomatically obese Primary prevention is for nonobese indi