Prevalence of Normal Weight Obesity Amongst Young Adults in the Southeastern United States

Authors: Helena Pavlovic, Tristen Dolesh, Christian Barnes, Angila Berni, Nicholas Castro, Michel Heijnen, Alexander McDaniel, Sarah Noland, Lindsey Schroeder, Tamlyn Shields, Jessica Van Meter, and Wayland Tseh*

AUTHORS INSTITUATIONAL AFFILIATION: School of Health and Applied Human Sciences, University of North Carolina Wilmington, Wilmington, North Carolina, United States of America

Drawing from antecedent research studies, dual-energy X-ray absorptiometry (DXA) is acknowledged as the clinical gold standard for appraising body composition (9, 10, 12, 21, 25, 26, 42, 47). However, a notable drawback of DXA lies in its emission of low-level radiation (6, 9, 32, 45, 47), thereby subjecting clients to unnecessary radiation exposure (1, 33). An alternative method is utilizing the BOD POD^® Gold Standard (GS), which employs air displacement plethysmography to estimate body composition. Previous literature has heralded the BOD POD^® GS as the applied, pragmatic gold standard for assessing body composition due to its validity (2, 7, 38), as well as its within- and between-day reliability (48). Additionally, owing to the BOD POD^® GS’s facile and non-invasive procedures, most individuals can attain accurate measures of body composition values, specifically pertaining to percent body fat, enabling the discernment of pounds of fat-free mass and fat mass.

According to the American College of Sports Medicine (ACSM), males with a percent body fat ≥ 25% and females ≥ 32% (4) are predisposed to an elevated risk of developing a myriad of hypokinetic diseases, notably cardiovascular disease(s), metabolic syndrome, and cardiometabolic dysfunction (14, 27, 35, 37, 39, 40, 43, 44, 46, 51, 56). Another evaluative approach involves the calculation of Body Mass Index (BMI), derived from dividing body weight in kilograms by square of height in meters (4). Given the ease and efficiency of calculating BMI, the obesity-related classification in which it provides at the individual level is potentially flawed (3, 8, 22, 24, 41, 53, 56).

Presently, within the United States, a dearth of research exists on the prevalence of normal weight obesity (NWO) amongst apparently healthy young adults (11,52). Normal weight obesity is characterized by individuals exhibiting a low BMI (<18>-2) or normal BMI (18.5 – 24.9 kg∙m^-2) yet manifesting obesity-related percentage body fat values (male = ≥20%; female = ≥30%) (5, 14, 20, 36, 37, 40, 43, 44, 57). Individuals with low/normal BMI and high percentage body fat values face an augmented risk of hypokinetic diseases, as their seemingly normal exterior masks a deleteriously high amount of body fat beneath the surface layer. Previous research endeavors have revealed the prevalence of NWO amongst a population of South Americans (14, 34, 40, 44), Central Europeans (15), and Asians (28-30, 37, 54, 55, 57, 58). Given that most aforesaid research studies on NWO have been conducted internationally, it is of paramount interest to ascertain the prevalence of NWO domestically. Consequently, the primary objective of this research study is to investigate the prevalence of normal-weight obesity among a sample of ostensibly healthy males and females.

METHODS

Participants

All participants were required to report to the Body Composition Laboratory to complete a singular session. Before the participants arrived, volunteers were instructed to abstain from consuming caffeinated sustenance or beverages that may acutely influence body mass. Moreover, researchers advised participants to refrain from vigorous physical activity/exercise the night before and prior to their appointed session. Upon arrival, volunteers read and signed an informed consent form approved by the University’s Institutional Review Board for human subject use (IRB#: H23-0499). As displayed in Table 1, a cohort comprising 254 male and female volunteers were recruited to participate in this study.

Below highlights the details of the singular Session required for each participant.

Body Mass Index (BMI)

Before each assessment, participants were asked to remove any unattached item(s) from their body, such as shoes, socks, rings, bracelets, and/or glasses.  Height was measured to the nearest 0.5 cm as participants stood barefoot, with both legs together, with their back to a Seca 217 Mobile Stadiometer (Model Number 2171821009, USA).  Body mass was measured on a Tanita Multi-Frequency Total Body Composition Analyzer with Column (Model DC-430U, Tanita Corporation, Japan) to the nearest 0.1 kg.  Body mass index was calculated using body mass expressed in kilograms (kg) divided by height expressed in meters squared (m²).  Body mass index categorizations, set forth via ACSM (4), for low BMI was (<18>-2) and normal BMI was (18.5 – 24.9 kg∙m^-2).

BOD POD^® Gold Standard (GS)

BOD POD^® Gold Standard (GS) (COSMED USA Inc., USA) was calibrated daily according to the manufacturer’s instructions with a 50.238 Liter cylindrical volume provided by COSMED USA Inc.  Specific details illustrating the technicalities of the calibration mechanism are published elsewhere (16, 18).  Because different clothing schemes have been shown to underestimate percentage body fat (%BF) results from the BOD POD^® (19, 49), female participants were instructed to wear one- or two-piece bathing suit or sports bra and compression shorts, while male participants were instructed to wear form-fitted compression shorts.  All participants wore a swim-like cap provided by COSMED USA Inc.  After race, height, and age were inputted by a technician into the BOD POD^® GS kiosk, participants were asked to step on an electronic scale to determine body mass to the nearest .045 kg.  Once the BOD POD^® GS system recorded body mass, participants were instructed to sit comfortably and breathe normally within the BOD POD^® GS for two trials lasting 40 seconds per trial.  A third trial was conducted if Trials 1 and 2 had high variability.  Once both (or three) trials were conducted, body composition values, specifically, body mass, percent body fat, fat-free mass, and fat mass, were immediately displayed on the kiosk viewer and recorded by a technician.  Once height, body mass, and body composition assessments were completed, participants dressed back into their original clothing and exited the Body Composition Lab.

Statistical Analyses

Descriptive statistics (mean ± SD) were derived to describe the sample population.  A Chi-Square Goodness of Fit Test was used to determine the prevalence of low/normal BMI values with obesity-related percent body fat.  For all analyses, statistical significance was established at p < 0.05.

RESULTS

At the conclusion of the study, 254 volunteers were recruited, and zero dropped out, therefore, all 254 participants’ results were included in the statistical analyses. Table 2 displays the descriptive measures of the study participants.

The chi-squared statistic was 1.886 (df = 1, p = 0.17) indicating no statistical difference in NWO between males (17.2%) and females (9.8%).

DISCUSSION

As stated previously, there is a dearth of data determining the prevalence of NWO domestically, more specifically, within the southeast region of the United States.  Therefore, the primary objective of this research study was to investigate the frequency of NWO amongst a sample of apparently healthy individuals.  Participants completed a singular data collection session whereby height, body mass, and percentage body fat were quantified via BOD POD^® GS.  Within this current study, low and normal BMI classifications were <18>-2 and 18.5 – 24.9 kg∙m^-2, respectively.  Class I obesity for females and males were ≥ 32% and ≥ 25%, respectively.  Given said thresholds, data revealed that 12.2% of the overall sample exhibited NWO, with a higher prevalence amongst males (17.2%) compared to females (9.8%).  These findings are relatively comparable within other research investigating the prevalence of NWO amongst a sample of young adults (5, 35, 44, 57).

In 2017, Ramsaran and Maharaj investigated the prevalence of NWO within a cohort of 236 young adults (mean age = 21.3 ± 2.5 years).  The quantification of %BF was accomplished using the Tanita Ironman body composition analyzer.  Subsequent data analyses unveiled a heightened prevalence of NWO among the male participants (14.4%), surpassing their female counterparts (5.5%).  The outcomes of the current study align with the findings reported by Ramsaran and Maharaj (44), wherein NWO manifested in 17.2% of males and 9.8% of females. A nuanced distinction between the two investigations lies in the designated thresholds for %BF. Ramsaran and Maharaj (44) set the elevated %BF thresholds at ≥ 23.1% for males and ≥ 33.3% for females. In contrast, the current study employed thresholds of ≥ 25.0% for males and ≥ 32.0% for females.  Notwithstanding the marginal elevation (+1.9%) in the %BF threshold within the current study, males exhibited a greater prevalence (+2.8%) compared to Ramsaran and Maharaj’s (44) dataset.  Conversely, the current study adopted a lower %BF threshold (–1.3%) for females and uncovered a higher prevalence of NWO (+4.4%).  These subtle yet discernible variations in %BF thresholds may elucidate the divergent prevalence rates of NWO observed between the two scholarly investigations.

Akin to Ramsaran and Maharaj (44) and the present investigation, Anderson and colleagues (5) examined the incidence of NWO within a more modest cohort of 94 young adults (mean age = 19.6 ± 1.5 years).  The quantification of %BF was assessed via DXA. The %BF thresholds were predicated on National Health and Nutrition Examination Survey standards, establishing obesity values of ≥ 30.0% for males and ≥ 35.0% for females.  Findings elucidated an NWO prevalence in males (26.7%) and females (7.8%). Noteworthy is the marked elevation in male NWO rates (+9.5%) and marginal reduction (–2.0%) in female NWO rates compared to the current study.  While discrepancies may be attributed to variances in sample size (254 in the present study vs. 94 in Anderson et al.), divergent methodologies for %BF assessment (utilizing BOD POD® GS presently as opposed to DXA in Anderson et al.), and distinct %BF thresholds (ACSM criteria in the current study versus NHANES in Anderson et al.), the overarching findings remain concordant. Specifically, data from all three research investigations underscore the consistent pattern wherein males manifest elevated NWO prevalence rates relative to their female counterparts.

In contradistinction to the two previous research investigations and the current study, Zhang et al. (57) explored the NWO prevalence amongst 383 young adults (mean age = 20.4 ± 1.6 years). Assessment of %BF was executed through bioelectrical impedance analyses (BIA) employing the InBody 720 device. Obesity classification was contingent upon threshold values of ≥20.0% for males and ≥30.0% for females, as established by Zhang and associates (57).  Analyses unveiled an NWO prevalence of 13.2% in males and 27.5% in females, a prominent deviation from the present study’s findings. The contrasting NWO prevalence patterns observed between the two studies are notably discernible. Specifically, Zhang and colleagues (57) reported a higher prevalence in females than males, whereas the current investigation revealed the converse. This discordance is seemingly attributable to variances in the %BF thresholds implemented for obesity classification. Zhang et al. (57) utilized a considerably lower threshold for males at 20.0%, as opposed to the 25.0% threshold applied in the current study. Similarly, for females, Zhang et al. (57) employed a lower %BF threshold at 30.0%, whereas the present study utilized a more conservative threshold of 32.0%. Moreover, a salient methodological distinction lies in the apparatus employed for %BF quantification. The current study utilized the BOD POD^® GS, acknowledged as the applied gold standard for assessing body composition, while Zhang et al. (57) employed the InBody 720 BIA. These methodological nuances likely contribute to the divergent findings between the present research and Zhang et al. (57), underscoring the importance of rigorously evaluating both threshold criteria and assessment modalities when interpreting and comparing NWO prevalence data.

In a recent investigation, Maitiniyazi et al. (35) endeavored to ascertain the prevalence of NWO within a cohort of 279 young adults (mean age = 21.7 ± 2.1 years). Percentage body fat was assessed utilizing the InBody 770 BIA method.  Obesity classification thresholds were established at 20.0% for males and 30.0% for females.  Parallel to the observed NWO patterns delineated by Zhang and colleagues (57), Maitiniyazi et al. also discerned a higher prevalence of NWO in females (40.1%) as opposed to males (25.5%).  Notably, while these NWO trends align with the patterns identified by Zhang et al. (57), they markedly deviate from the outcomes of the current investigation.  Such discordant findings may find elucidation in the nuanced disparities in the thresholds employed to categorize obesity and the instrumentation deployed for %BF quantification.  Specifically, the divergence in %BF thresholds used for obesity classification emerges as a significant factor. Maitiniyazi et al. (35) employed thresholds different from those of Zhang et al. (57) and the current study, thereby contributing to the observed inconsistencies. Additionally, the equipment utilized to quantify %BF introduces another layer of methodological variation. While Zhang et al. (57) implemented InBody 720 BIA and the current study utilized BOD POD^® GS, Maitiniyazi et al. deployed the InBody 770 BIA method.  These divergent methodological approaches underscore the imperative of meticulous consideration when interpreting and comparing NWO prevalence data, highlighting the multifaceted nature of the interplay between obesity thresholds and assessment methodologies in elucidating NWO prevalence.

CONCLUSIONS

This comprehensive investigation contributes significantly to our understanding of NWO prevalence within a young adult population, particularly within the Southeast region of the United States.  The study employed the BOD POD^® GS for precise measurement of height, body mass, and percentage body fat, revealing a higher, but not statistically different, prevalence in NWO between males and females.  These results align with similar studies collectively emphasizing the consistent pattern of elevated NWO prevalence in males relative to females.  The study’s alignment with said research investigations further underscores the robustness of the findings, notwithstanding variations in sample size, methodology, and threshold criteria.  Conversely, discrepancies with other research investigations highlight the sensitivity of NWO prevalence to %BF thresholds and assessment modalities.  Despite the divergence in outcomes, these studies collectively reinforce the need for careful consideration of methodological nuances in interpreting and comparing NWO prevalence data.

APPLICATION IN SPORTS

From a practical perspective, the findings emphasize the importance of incorporating regional and demographic variations when assessing NWO prevalence.  Furthermore, the study underscores the relevance of employing standardized methodologies in ensuring consistency and comparability across investigations.  Future endeavors in this domain should continue to explore regional variations, refine %BF threshold criteria, and employ advanced methodologies for accurate NWO characterization.  This knowledge is pivotal for tailoring preventive measures and interventions; more precisely, accurately identifying NWO individuals is an opportunity for clinicians to proactively educate their clients regarding the health risks associated with hypokinetic disease(s), particularly cardiovascular disease(s), metabolic syndrome, and cardiometabolic dysfunction.

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