Dietary Planning Across the Lifespan NMDD221 Session 2 Anthropometric Assessment Nutritional Medicine Department Endeavour College of Natural Health endeavour.edu.au 1
Overview BMI, hip and waist measurements, skin fold, and bioelectrical impedance analysis Interpretation of body fat and lean muscle mass in relation to dietary planning Changes in lean muscle mass as a predictor of catabolic and anabolic states and nutritional implications and management Endeavour College of Natural Health endeavour.edu.au 2
Anthropometric Assessment Anthropometry is the science of measuring the human body. Not diagnostic on its own must be supported by other measures of nutritional status. Main purposes: Monitor progress of growth (e.g. infants, pregnancy) Detect undernutrition or overnutrition in all age groups Measure changes in body composition over time Used together with other assessment methods to develop nutrition care plan Endeavour College of Natural Health endeavour.edu.au 3
Anthropometric Assessment When conducting an anthropometric assessment each measure requires: Use of standardised techniques Calibrated instruments Trained personnel Endeavour College of Natural Health endeavour.edu.au 4
Anthropometric Assessment The anthropometric measures that are used most commonly in clinical practice are: Body Mass Index (BMI) requires height and weight (kg/m 2 ) Waist circumference Waist to hip ratio These measures are very useful and do not require expensive equipment but have limitations. Sometimes more precise methods of assessing body composition are required. Endeavour College of Natural Health endeavour.edu.au 5
Measuring Height Use a height rule taped vertically to a hard, flat wall, with the base at floor level. Ask the person to remove their shoes, heavy outer garments, and hair ornaments. Ask the person to stand with his or her back to the height rule. The back of the head, back, buttocks, calves and heels should be touching the wall, and the person s feet together. Ask the person to look straight ahead. Press hair flat and record height. If the person is taller than the measurer, the measurer should use a platform to avoid parallax error. (National Health and Medical Research Council [NHMRC], 2013, p.24) Endeavour College of Natural Health endeavour.edu.au 6
Measuring Weight Use a regularly calibrated scale on a hard, level surface. Ask the person to remove shoes and heavy outer garments (coat, jacket). Ask the person to stand centred on the scale with weight evenly on both feet. Record the weight. If the person weighs more than the scale can measure, note this and the upper limit of the scale. (NHMRC, 2013, p.24) Endeavour College of Natural Health endeavour.edu.au 7
Body Mass Index (BMI) BMI is a weight-for-height index that is commonly used to classify underweight, overweight, and obesity in adults. It is the main measure used in international obesity guidelines. BMI thresholds are the same for both sexes (NHMRC, 2013) It is recommended by the World Health Organization (WHO, 2016) Endeavour College of Natural Health endeavour.edu.au 8
BMI Calculation BMI = weight (kg)/height (m) 2 Example: Male 35 years of age Weight = 70 kg; Height = 1.75 m BMI = 70/1.75 2 (1.75 X 1.75) BMI = 22.86 kg/m 2 What would his BMI classification be? Endeavour College of Natural Health endeavour.edu.au 9
BMI Classification in Adults Classification BMI (kg/m 2 ) Principal cut-off points Additional cut-off points Underweight <18.50 <18.50 Severe thinness <16.00 <16.00 Moderate thinness 16.00-16.99 16.00-16.99 Mild thinness 17.00-18.49 17.00-18.49 Normal range 18.50-24.99 18.50-22.99 23.00-24.99 Overweight 25.00 25.00 Pre-obese 25.00-29.99 25.00-27.49 27.50-29.99 Obese 30.00 30.00 Obese class I 30.00-34.99 30.00-32.49 32.50-34.99 Obese class II 35.00-39.99 35.00-37.49 37.50-39.99 Obese class III 40.00 40.00 (WHO, 2016) Endeavour College of Natural Health endeavour.edu.au 10
BMI - Interpretation At a population level, increased mortality and higher incidence of disease related to increased fat mass are seen most markedly when BMI rises above 30 kg/m 2. Individuals with the same BMI may have different ratios of body fat to lean mass. Women have more body fat than men at equivalent BMI. Different BMI thresholds may need to be considered for different ethnic groups. An older person will generally have more body fat than a younger person with the same BMI due to loss of lean tissue with age. (NHMRC, 2013) Endeavour College of Natural Health endeavour.edu.au 11
BMI and Obesity Worldwide obesity has more than doubled since 1980. In 2014, more than 1.9 billion adults (18 years and older) were overweight. Of these over 600 million were obese. 39% of adults aged 18 years and over were overweight, and 13% were obese. Most of the world s population live in countries where overweight and obesity kills more people than underweight. 41 million children under the age of 5 were overweight or obese in 2014. Obesity is preventable (WHO, 2016). Endeavour College of Natural Health endeavour.edu.au 12
Activity Working in pairs measure the height and weight of your partner and calculate BMI (kg/m 2 ). Endeavour College of Natural Health endeavour.edu.au 13
Waist Circumference Waist circumference is a good indicator of total body fat and is also a useful predictor of visceral fat. Compared to BMI, waist circumference is a better predictor of cardiovascular risk, type 2 diabetes (in women, but not in men) and metabolic syndrome. Waist circumference is not an accurate measure of body fat in some situations such as pregnancy or medical conditions where there is distension of the abdomen. (NHMRC, 2013) Endeavour College of Natural Health endeavour.edu.au 14
Measuring Waist Circumference Use a measuring tape that is checked monthly for stretching (replace if stretched). Ask the person to remove heavy outer garments, loosen any belt and empty pockets. Ask the person to stand with their feet fairly close together (about 12 15 cm) with their weight equally distributed and to breathe normally. Holding the measuring tape firmly, wrap it horizontally at a level midway between the lower rib margin and iliac crest (approximately in line with the umbilicus). The tape should be loose enough to allow the measurer to place one finger between the tape and the person s body. Record the measurement taken on an exhalation. (NHMRC, 2013, p. 26) Endeavour College of Natural Health endeavour.edu.au 15
Waist and Hip Circumferences Endeavour College of Natural Health endeavour.edu.au 16
Waist and Hip Circumferences The waist circumference should be measured at the midpoint between the lower margin of the last palpable rib and the top of the iliac crest, using a stretch resistant tape that provides a constant 100 g tension. Hip circumference should be measured around the widest portion of the buttocks, with the tape parallel to the floor. Endeavour College of Natural Health endeavour.edu.au 17
Waist to Hip Ratio o The waist to hip ratio is calculated by dividing the waist circumference by the hip circumference. o Example: waist = 82 cm; hips = 102 cm. WHR = 82/102 = 0.80 cm o The WHR has been used as an indicator or measure of the health of a person, and the risk of developing serious health conditions. Research shows that people with apple-shaped bodies (with more weight around the waist) face more health risks than those with "pearshaped" bodies who carry more weight around the hips. Endeavour College of Natural Health endeavour.edu.au 18
Interpretation Waist Circumference and WHR: For women a waist circumference 80 cm indicates increased risk of chronic disease and 88 cm indicates high risk. For men a waist circumference 94 cm indicates increased risk of chronic disease and 102 cm indicates high risk. The at risk WHR for women is > 0.8 and for men > 0.9. Different thresholds may need to be considered for different ethnic groups. Endeavour College of Natural Health endeavour.edu.au 19
Activity Using a tape measure, work in pairs to measure your partner s waist and hip circumferences. Then calculate waist to hip ratio. Endeavour College of Natural Health endeavour.edu.au 20
Body Composition Numerous body composition models have been developed and numerous measurement methods are available. The available measurement methods range from simple to complex with all methods having limitations and some degree of measurement error (Lee & Gallagher, 2008). Endeavour College of Natural Health endeavour.edu.au 21
Body Composition Reading 2.1 A population-based approach to define body-composition phenotypes Increasing evidence suggests that the concurrent presence of HA-LM (High adipose-low muscle) may be associated with a more elevated health risk. The additive effects of abnormal muscle and adipose tissue content in an individual may lead to greater propensity for metabolic and cardiovascular deregulation, termed sarcopaenic obesity Endeavour College of Natural Health endeavour.edu.au 22
Body Composition Models Two of the most commonly used body composition models are the 2 compartment model and the 4 compartment model. 2 compartment model: BM = FM + FFM 4 compartment model: BM = FM + TBW + TBPro + M BM = Body Mass FM = Fat Mass FFM = Fat-Free Mass M = Mineral TBPro = Total Body Protein TBW = Total Body Water Endeavour College of Natural Health endeavour.edu.au 23
Body Composition Measurement Examples of body composition measurement methods include: Skinfold measures Bioelectrical impedance analysis (BIA) Dual energy X-ray absorptiometry (DXA) Hydrodensitometry Air displacement plethysmography (ADP) Endeavour College of Natural Health endeavour.edu.au 24
Skinfold Measures Skinfold measures provide a good estimate of total body fat and a fair assessment of the fat s location providing the measurements are carried out properly. Approximately half the fat in the body lies directly beneath the skin and the thickness of this subcutaneous fat reflects total body fat. To measure skinfolds a skilled assessor follows a standard procedure using reliable callipers and then compares the measurement with standard tables. (Whitney, 2016) Endeavour College of Natural Health endeavour.edu.au 25
Skinfold Measures The Durnin and Womersley method for determining body density uses the sum of 4 skinfold measures: biceps, triceps, subscapular and anterior suprailiac. The Jackson and Pollack method uses the sum of 7 skinfold measures: chest, mid-axillary, triceps, subscapular, abdominal, anterior suprailiac and anterior thigh. Endeavour College of Natural Health endeavour.edu.au 26
Skinfold Measures Endeavour College of Natural Health endeavour.edu.au 27
Skinfold Measures Procedure: Two hands are required for correct technique. Measurements are taken on the right side of the body whilst in the standing position (except may be seated for the anterior thigh). Note that small errors in placement may produce large errors in calculated body fat percentage (%BF). The reading should be taken close to 2 seconds after applying the calliper spring-tension to the skinfold. Skin should be dry and lotion-free. Do not measure immediately after exercise due to shifts in body fluid. Endeavour College of Natural Health endeavour.edu.au 28
Standard Skinfold Sites Triceps At the level of the midpoint between the acromial (lateral edge of the acromial process, e.g. bony tip of shoulder) and the radial (proximal and lateral border of the radius bone, approximately the elbow joint), on the mid-line of the posterior (back) surface of the arm (over the triceps muscle). Endeavour College of Natural Health endeavour.edu.au 29
Standard Skinfold Sites Triceps (cont..) The Pinch: The arm should be relaxed with the palm of the hand facing forwards (supinated). A vertical pinch, parallel to the long axis of the arm, is made at the landmark. Endeavour College of Natural Health endeavour.edu.au 30
Standard Skinfold Sites Biceps Landmark: At the level of the mid-point between the acromial (lateral edge of the acromial process, e.g. bony tip of shoulder) and the radial (proximal and lateral border of the radius bone, approximately the elbow joint), on the mid-line of the anterior (front) surface of the arm (over the biceps muscle). Endeavour College of Natural Health endeavour.edu.au 31
Standard Skinfold Sites Biceps (cont ) The arm should be relaxed with the palm of the hand facing forwards. A vertical pinch, parallel to the long axis of the arm, is made at the landmark. Endeavour College of Natural Health endeavour.edu.au 32
Standard Skinfold Sites Subscapular Skinfold Endeavour College of Natural Health endeavour.edu.au 33
Standard Skinfold Sites Subscapular Skinfold Landmark: The lower angle of the scapula (bottom point of shoulder blade) If there is difficulty finding this landmark, get the subject to reach behind their back with their right arm, while feeling for the movement of the scapula Pinch The pinch is made following the natural fold of the skin, approximately on a line running laterally (away from the body) and downwards (at about 45 degrees). Endeavour College of Natural Health endeavour.edu.au 34
Standard Skinfold Sites Thigh Skinfolds The mid-point of the anterior (front) surface of the thigh, midway between patella (knee cap) and inguinal fold (crease at top of thigh). Endeavour College of Natural Health endeavour.edu.au 35
Standard Skinfold Sites Illiac crest Landmark: Immediately above the iliac crest (top of hip bone), on the most lateral aspect (side). Endeavour College of Natural Health endeavour.edu.au 36
Standard Skinfold Sites Supraspinale Skinfold The supraspinale skinfold site is one of the common locations used for the assessment of body fat using skinfold calipers. It has previously been known as the Suprailiac site. Landmark: The intersection of a line joining the spinale (front part of iliac crest) and the anterior (front) part of the axilla (armpit), and a horizontal line at the level of the iliac crest. Endeavour College of Natural Health endeavour.edu.au 37
Standard Skinfold Sites Abdominal Skinfold Landmark: a mark is made 5 cm adjacent to the umbilicus (belly-button), to the right side. Pinch The vertical pinch is made at the marked site, and the calipers placed just below the pinch. Be careful not to place the caliper or fingers inside the navel. Endeavour College of Natural Health endeavour.edu.au 38
Standard Skinfold Sites Landmark for Medial Calf A point on the medial (inside) surface of the calf, at the level of the largest circumference. A tape measure should be used to determine this point. Pinch The subject should place their foot on a chair or box so that the knee is at approximately 90 degrees. A vertical pinch parallel to the long axis of the leg Endeavour College of Natural Health endeavour.edu.au 39
Standard Skinfold Sites Chest (Pectoral) Skinfold The pinch is taken at a point between the axilla and nipple as high as possible on the anterior axillary fold. The chest or pectoral skinfold site is one of the less common locations used for the assessment of body fat using skinfold callipers. Endeavour College of Natural Health endeavour.edu.au 40
Bioelectrical Impedence Endeavour College of Natural Health endeavour.edu.au 41
Bioelectrical Impedence Bioelectrical impedance analysis (BIA) is a commonly used method for estimating body composition. BIA determines the electrical impedance, or opposition to the flow of an electric current through body tissues which can then be used to calculate an estimate of total body water (TBW). TBW can be used to estimate fat-free body mass and, by difference with body weight, body fat. Endeavour College of Natural Health endeavour.edu.au 42
Bioelectrical Impedence Recent technological improvements have made BIA a more reliable and therefore more acceptable way of measuring body composition. It is not however a gold standard or reference method. Like all assessment tools, the result is only as good as the testing parameters. Endeavour College of Natural Health endeavour.edu.au 43
Bioelectrical Impedence The Procedure As the bioelectric impendence device measures the resistance of body tissues to the flow of a small electrical signal, the person being measured should not be in contact with any other non conducting surface, with legs apart and arms away from the body. Some devices require a pair of electrodes to be placed on the hand and wrist, and another pair placed on the ankle and foot (usually opposite sides of the body), while other devices simply require the client to stand on two foot plates. Endeavour College of Natural Health endeavour.edu.au 44
Bioelectrical Impedence Endeavour College of Natural Health endeavour.edu.au 45
Bioelectrical Impedence Advantages o Simple and quick to perform o Reasonably accurate with modern machine in stable, temperate environment o Portable Disadvantages Machines are expensive If the person is dehydrated a higher fat reading will be given Does not take into account the location of body fat. Older machines can be inaccurate Endeavour College of Natural Health endeavour.edu.au 46
Ideal Body Fat Percentage Ideal body fat percentages will vary based on age, activity levels, gender and life stage. As a general rule: Women: 22 28% Men : 16 23% Women who have a body fat percentage >32% and men > 25% are at much higher risk of metabolic disease and obesity. Important to consider location of body fat i.e. apple shaped people who carry fat around the waist are at higher risk of metabolic disease than those who are pear shaped (and carry their weight around their hips) (Mahan, 2012) Endeavour College of Natural Health endeavour.edu.au 47
Dietary planning for reducing body fat percentage Set realistic and achievable goals with the patient To achieve the best possible weight in the context of overall health and wellbeing Consider diet and lifestyle recommendations (physical activity) Review overall kilojoule intake Where are the patient s kilojoules coming from? Nutrient dense food or energy dense food? Therapeutic Diet Recommendations Low GI diet or Reduced carbohydrate diet (Mahan, 2012) Endeavour College of Natural Health endeavour.edu.au 48
Dietary planning for reducing body fat percentage Behavioural practices around food/ eating Eating on the run Frequency of eating (either too often or too little) Emotional eating Portion control Serving sizes (Education around what is a serve ) (Mahan, 2012) Endeavour College of Natural Health endeavour.edu.au 49
Lean Muscle Mass Ideal muscle percentage reference ranges are not normally quoted as the focus is usually on Body Fat %. Some sources and websites recommend people should aim for >36% muscle mass, however this figure lacks scientific rigour and will vary based on the individual, their stage of life and their type and amount of physical activity. Sarcopaenia is defined as a loss of the amount, quality and strength of lean muscle mass as we age. Commonly experienced beyond 50 years of life although can happen earlier due to lack of physical activity. Commonly diagnosed via anthropometric assessment like dual-energy X-ray absorptiometry (DXA) or BIA. (Mahan, 2012) Endeavour College of Natural Health endeavour.edu.au 50
Calculating Body Fat Percentages based on 4 skin fold measurements Add up skin fold measurements for the biceps, triceps, subscapular and suprailiac skin folds. Refer to a created Table (eg: Krause s food and the nutrition care cycle, Appendix 24, page 1068). Look up the sum and then correlate this to the patients gender and age bracket. Example: Biceps 17.0 mm; Triceps 17.0 mm; Subscapular 20.0 mm and Suprailiac 16.0 mm. Total = 70. (Mahan, 2012) Endeavour College of Natural Health endeavour.edu.au 51
Calculating Body Fat Percentages based on 4 skin fold measurements (Mahan, 2012) Endeavour College of Natural Health endeavour.edu.au 52
Ideal Body Weight The formula for calculating ideal weight is: (Lean body mass in kg) (1- percentage ideal body fat in decimals) Where: lean body mass = weight in kg fat weight in kg fat weight = weight in kg X percentage body fat See example on next slide. Endeavour College of Natural Health endeavour.edu.au 53
Ideal Body Weight Example Example: a man weighs 100 kg and has 30% body fat. Fat weight can be calculated as 100 X 0.30 (i.e. body weight in kg X percentage of body fat) = 30 kg. Lean body mass can be calculated as 100 30 = 70 kg A short term goal for this man might be to get to 25% body fat. In that case, ideal weight would be calculated as: 70/(1-0.25) = 93.5 kg Endeavour College of Natural Health endeavour.edu.au 54
Activity Calculate the ideal body weight for the man in the previous example if he was aiming for 20% body fat and then 18% body fat. Endeavour College of Natural Health endeavour.edu.au 55
Catabolism and Anabolism in Relation to Dietary Planning Endeavour College of Natural Health endeavour.edu.au 56
Lean Muscle Mass Lean Muscle Mass (LMM) is an important biomarker for longevity and good health. The maintenance of lean muscle mass has been clinically shown to guard against obesity, protect against bone demineralisation, aids cellular insulin and glucose sensitivity, maintains strength in older people, reduces depression risk, improves male and female hormone ratios, and lowers cardiovascular risks. Conservation of muscle mass is important for fall and fracture prevention in older adults (Welch, 2013). Endeavour College of Natural Health endeavour.edu.au 57
Lean Muscle Mass Building and maintaining lean muscle mass is dependent on age, diet, exercise, stress levels, hormone status, genetics and environmental factors. Diet can have a positive impact on optimising lean muscle mass in many people, especially when combined with exercise. Protein turnover involves a delicate balance of anabolic and catabolic mechanisms. In healthy muscle, proteins and amino acids constantly turn over in equilibrium between protein synthesis and breakdown. Endeavour College of Natural Health endeavour.edu.au 58
Anabolic Factors Insulin and insulin-like growth factor 1 (IGF-1) signalling lead to protein synthesis through activation of several pathways. Adequate dietary protein intake is required for building and maintaining lean muscle mass. There is a general agreement that leucine (an essential amino acid) increases protein anabolism and decreases protein breakdown. Leucine-rich food sources include legumes such as soybeans and cowpea, and animal products such as beef and fish (Waters, Baumgartner, Garry, & Vellas, 2010). Resistance training. Endeavour College of Natural Health endeavour.edu.au 59
Catabolic Factors Excess alcohol consumption decreased muscle protein synthesis. Tobacco smoking decreased muscle protein synthesis and increased muscle protein degradation. Inactive and sedentary lifestyle decreased muscle protein synthesis, increased muscle protein degradation and decreased muscle function and quality. Insufficient energy and protein intake decreased muscle protein synthesis, increased muscle protein degradation and decreased muscle function and quality. Vitamin D insufficiency decreased muscle function and quality. (Oren, Sharon, Dror, & Abraham 2012) Endeavour College of Natural Health endeavour.edu.au 60
Catabolic Factors (cont.) In males, testosterone decreases by 1% per year and bioavailable testosterone by 2% per year from age 30. In women, testosterone levels drop rapidly from 20 to 45 years of age. Dysregulated insulin signalling, increased cytokine expression and decreased antioxidant capacity can all lead to an imbalance in protein turnover, favouring degradation over synthesis (i.e. chronic inflammation and oxidative damage can have a catabolic effect on muscle). (Waters et al., 2010) Endeavour College of Natural Health endeavour.edu.au 61
Examples of catabolism Examples of catabolic states include: Protein-energy malnutrition (PEM) Cachexia Sarcopaenia Endeavour College of Natural Health endeavour.edu.au 62
Protein-energy malnutrition (PEM) Protein-energy malnutrition (PEM) is a pathologic depletion of the body s lean tissues caused by starvation, or a combination of starvation and catabolic stress. PEM develops when protein intake or energy intake, or both, chronically fail to meet the body s requirements for these nutrients (Hoffer, 2001). (Hoffer, 2001) Endeavour College of Natural Health endeavour.edu.au 63
Cachexia Cachexia is associated with medical conditions such as: sepsis cancer immunodeficiency disease food intake and appetite are decreased. In cachexia, inflammatory cytokines and cortisol secretion are greatly increased (Welch, 2013). Endeavour College of Natural Health endeavour.edu.au 64
Sarcopaenia The progression of sarcopaenia is affected by agerelated systemic changes and by lifestyle habits. Age-related changes include: reduction in anabolic hormones such as testosterone, oestrogen, growth hormone, and insulin-like growth factor-1 (IGF-1) increased inflammatory activity oxidative stress which contribute to muscle catabolism. Lifestyle habits have a major impact on sarcopaenia as well. These factors include impaired nutrition, reduced physical activity, alcohol consumption, and cigarette smoking. (Oren et al., 2012) Endeavour College of Natural Health endeavour.edu.au 65
Dietary Planning Dietary planning to address sarcopaenia is covered in Session 13, Older Adults. Endeavour College of Natural Health endeavour.edu.au 66
Tutorial Activities Endeavour College of Natural Health endeavour.edu.au 67
Tutorial Part A Demonstration Lecturer to demonstrate how to estimate body fat percentage based on skinfold method. Endeavour College of Natural Health endeavour.edu.au 68
Tutorial Part B Activity 1. Working in pairs, use the skinfold method to estimate body fat percentage for each person. 2. If BIA scales are available compare above calculation to body fat percentage as measured by BIA scales. 3. Calculate ideal body weight. Endeavour College of Natural Health endeavour.edu.au 69
Tutorial Part C Discussion Discuss the relevance and application of anthropometrics for nutritionists and naturopaths. Endeavour College of Natural Health endeavour.edu.au 70
References Hoffer, L. J. (2001). Clinical nutrition: 1. Protein-energy malnutrition in the inpatient. CMAJ: Canadian Medical Association Journal, 165(10), 1345-1349. Retrieved from http://www.ebscohost.com Lee, S., Gallagher, D., Lee, S. Y., & Gallagher, D. (2008). Assessment methods in human body composition. Current Opinion in Clinical Nutrition & Metabolic Care, 11(5), 566-572. doi:10.1097/mco.0b013e32830b5f23 National Health and Medical Research Council. (2013). Clinical practice guidelines for the management of overweight and obesity in adults, adolescents and children in Australia. Retrieved from https://www.nhmrc.gov.au/guidelines-publications/n57 Oren, R., Sharon, K., Dror, A., & Abraham Z., R. (2012). Lifestyle and Sarcopenia Etiology, Prevention, and Treatment. Rambam Maimonides Medical Journal, 3(4), e0024. doi:10.5041/rmmj.10091 Waters, D., Baumgartner, R., Garry, P., & Vellas, B. (2010). Advantages of dietary, exercise-related, and therapeutic interventions to prevent and treat sarcopenia in adult patients: an update. Clinical interventions in ageing, 2010 (5), 259-270. doi: org/10.2147/cia.s6920 Welch, A. A. (2014). Nutritional influences on age-related skeletal muscle loss. The Proceedings Of The Nutrition Society, 73(1), 16-33. doi:10.1017/s0029665113003698 Whitney, E. (2016). Understanding nutrition (3rd Australian and New Zealand ed.). South Melbourne, Vic: Cengage Learning. Endeavour College of Natural Health endeavour.edu.au 71
References World Health Organization. (2000). Obesity: Preventing and managing the global epidemic. Report of a WHO Consultation: WHO Technical Report Series 894. Retrieved from http://www.who.int/nutrition/publications/obesity/who_trs_894/en/ World Health Organization. (2016 a). BMI classification. Retrieved from http://apps.who.int/bmi/index.jsp?intropage=intro_3.html World Health Organization. (2016 b). Obesity and overweight. Retrieved from http://www.who.int/mediacentre/factsheets/fs311/en/ Endeavour College of Natural Health endeavour.edu.au 72
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