Assessment of Risk Status − Rakyat Biologi

The patient's risk status should be assessed by determining the degree of overweight or obesity based on BMI, the presence of abdominal obesity based on waist circumference, and the presence of concomitant CVD risk factors or comorbidities. Some obesity-associated diseases and risk factors place patients in a very high risk category for subsequent mortality. These diseases will require aggressive modification of risk factors in addition to their own clinical management. Other obesity-associated diseases are less lethal, but still require appropriate clinical therapy. Obesity also has an aggravating influence on several cardiovascular risk factors. Identifying these risk factors is required as a guide to the intensity of clinical intervention

Determination of Relative Risk Status

The table, below, defines relative risk categories according to BMI and waist circumference. It is important to note that these categories denote relative risk, not absolute risk. They relate to the need to institute weight loss therapy, and do not directly define the required intensity of risk factor modification. The latter is determined by estimation of absolute risk based on the presence of associated disease or risk factors.

Classification of Overweight and Obesity by
BMI, Waist Circumference and Associated Disease Risk

			Disease Risk Relative to Normal Weight and Waist Circumference
	BMI (kg/m²)	Obesity Class	Men 102 cm ( 40 in.) Women 88 ( 35 in.)	Men >102 cm ( >40 in.) Women >88 cm

(>35 in.)

Underweight

< 18.5

-----

Normal+

18.5 - 24.9

-----

Overweight

25.0 - 29.9

Increases

High

Obesity

30.0 - 34.9

High

Very High

35.0 - 39.9

Very High

Extreme Obesity

III

Extremely High

Determination of Absolute Risk Status

Determining the patient's absolute risk status requires consideration of the degree of overweight, as well as the presence of existing diseases or risk factors. To do so requires taking into account the patient's history, physical examination, and laboratory results. Of greatest urgency is the need to detect existing CVD or end-organ damage that trigger the need for intense risk factor modification as well as disease management. Since the major risk of obesity is indirect (obesity elicits or aggravates hypertension, dyslipidemias, and diabetes which cause cardiovascular complications), the management of obesity should be implemented in the context of these other risk factors. While there is no direct evidence demonstrating that addressing risk factors increases weight loss, treating the risk factors through weight loss is a recommended strategy

Identification of Cardiovascular Risk Factors That Impart a High Absolute Risk

Patients can be classified as being at high absolute risk for obesity-related disorders if they have three or more of the multiple risk factors listed below. The presence of high absolute risk increases the intensity of cholesterol lowering therapy and blood pressure management.

Cigarette smoking
Hypertension:
A patient is classified as having hypertension if systolic blood pressure is 140 mm Hg or diastolic blood pressure is 90 mm Hg, or if the patient is taking antihypertensive agents.
High-risk low-density lipoprotein cholesterol:
A high-risk LDL-cholesterol is defined as a serum concentration of 160 mg/dL. A borderline high-risk LDL-cholesterol (130 to 159 mg/dL) together with two or more other risk factors also confers high risk.
Low high-density lipoprotein cholesterol:
A low HDL-cholesterol is defined as a serum concentration of <35 mg/dL.
Impaired fasting glucose (IFG):
The presence of clinical type 2 diabetes (fasting plasma glucose of 126 mg/dL or 2 hours postprandial plasma glucose of 200 mg/dL) is a major risk factor for CVD, and its presence alone places a patient in the category of very high absolute risk. IFG (fasting plasma glucose 110 to 125 mg/dL) is considered by many authorities to be an independent risk factor for cardiovascular (macrovascular) disease, justifying its inclusion among risk factors contributing to high absolute risk. Although including IFG as a separate risk factor for CVD departs from the ATP II and JNC VI reports, its inclusion in this list may be appropriate. IFG is well established as a risk factor for type 2 diabetes.
Family history of premature CHD:
A positive family history of premature CHD is defined as definite myocardial infarction or sudden death at or before 55 years of age in the father or other male first-degree relative, or at or before 65 years of age in the mother or other female first-degree relative.
Age:
Male 45 years
Female 55 years (or postmenopausal)

Other Risk Factors

Other risk factors deserve special consideration for their relation to obesity. When these factors are present, patients can be considered to have incremental absolute risk above that estimated from the preceding risk factors. Quantitative risk contributions are not available for these risk factors, but their presence heightens the need for weight reduction in obese persons.

High triglycerides

Obesity is commonly accompanied by elevated serum triglycerides. The relationship between high triglycerides and CHD is complex. Triglyceride-rich lipoproteins may be directly atherogenic. In addition, elevated serum triglycerides are the most common manifestation of the atherogenic lipoprotein phenotype (high triglycerides, small LDL particles, and low HDL-cholesterol levels. Moreover, in the presence of obesity, high serum triglycerides are commonly associated with a clustering of metabolic risk factors known as the metabolic syndrome (atherogenic lipoprotein phenotype, hypertension, insulin resistance and glucose intolerance, and prothrombotic states). Thus, in obese patients, elevated serum triglycerides are a marker for increased cardiovascular risk. According to current guidelines (ATP II and JNC VI), the presence of high triglycerides does not modify the intensity of cholesterol or blood pressure lowering therapy. Their presence in obese patients, however, calls for an intensified effort to achieve weight reduction and increase physical activity. Both will reduce the various risk factors characteristic of the metabolic syndrome, and thus should reduce overall cardiovascular risk as well as decrease the risk for type 2 diabetes.

According to the ATP II guidelines, triglyceride levels are classified as follows:

Category	Serum Triglyceride Levels
Normal triglycerides	Less than 200 mg/dL
Borderline-high triglycerides	200 to 400 mg/dL
High triglycerides	400 to 1,000 mg/dL
Very high triglycerides	Greater than 1,000 mg/dL