Risk for these problems increases in a dose-response fashion -- the greater the excess weight, the greater the risk. The typical middle-age weight gain experienced by many North Americans of 20 to 30 pounds appears to increase health risks. For example, one study found that women who added 22 to 40 pounds after age 18 had a 70 percent greater risk of death from heart disease and a 20 percent greater risk of cancer than women who had maintained their weight. Is obesity the real culprit? A remaining question is whether obesity is the real cause of the health risks listed above, or simply a marker for other lifestyle factors that represent the real risk, such as a sedentary lifestyle and poor eating habits. Some evidence suggests that excess body fat probably interacts with heredity and lifestyle to affect metabolic processes, such as blood sugar regulation, that are associated with health risks. While studies of large groups support the relationship between obesity and health risk, it is hard to say how fat is too fat for any given individual. Height-weight tables are the only general guidelines available, but these may not be helpful in every case. In addition to consulting a height-weight table, the following issues should be considered: Body composition. More important than weight is body composition -- how much of a person's weight is adipose tissue? Very muscular people may find themselves "too heavy" according to the tables when in reality they are very healthy. Likewise, you have probably worked with clients who fall within the allowable weight range on the height-weight chart, but are too fat according to body composition estimates. When working with clients, keep in mind that body composition estimates are just that -- estimates. Combined with other information they can be useful. Location of fat stores. People who carry extra fat on the torso are at greater risk for hypertension, type II diabetes and artery disease, than people whose extra fat resides in the hips and thighs. Lower body obesity is a lesser health risk; however, people with "pear shapes" are still at higher risk for obesity-related disorders than people who are not overweight.

Medical history and family medical history. Weight loss is especially important for people who have obesity-related health problems, such as high blood pressure, type II diabetes, high blood lipids or artery disease, or a family history of these disorders.

Age. What if your client is over 70 years old, a bit overweight, but apparently healthy with normal blood pressure, blood lipids and blood sugar? Weight loss in this case is probably not too important. In fact, many nutritionists recommend an extra 10 or 15 pounds for people over 70 to help them resist wasting if they should become ill.

Setting a realistic weight goal

If clients are way over their desirable weight, it may not be realistic to get down to a weight on the chart. The good news is that the first 10 to 15 pounds of weight loss has the greatest health benefits, and can result in a significant reduction of blood pressure, cholesterol and blood sugar. A focus on the scale can be frustrating. The best way to help overweight clients maintain good health or improve health status is to help them focus on fitness rather than fatness. Encourage a healthful lifestyle, and health benefits will accrue whether weight loss occurs or not.

REFERENCES

Gaesser, G. "Does shaping up require changing shape?" Presentation at conference, Diet and Exercise Adherence, March 28, 1996, Amherst, MA.

Browned, K. "Dieting and the search for the perfect body: The clash of physiology and culture." Presentation at conference, Diet and Exercise Adherence, March 28, 1996, Amherst, MA.

Medical experts now see obesity as a chronic condition that is remarkably resistant to treatment. Obesity rates in American adults and children continue to climb, with no reversal of this trend in sight.

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