The “Skinny” on BMI for
Transplantation
Outline
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Body mass index (BMI)
Measure of body weight
Alternative ways to assess body fat
Weight after transplant
Setting criteria for your center
(No Disclosures)
What do these women have
in common?
The same Body Mass Index (BMI)
Evolution of the term
“Body Mass Index”
1972 Ancel Keys, “Indices of Relative Weight and Obesity.”
Landmark study on body-fat percentage:
− 7400 men in five countries
− Compared formulas to directly measured values
Confirmed the best predictor:
− Adolphe Quetelet’s formula of the “average man” from 1835
(weight divided by height squared)
Keys renamed it Body Mass Index
Shah, B. (2006). Comparison of Ideal Body Weight Equations and Published Height-Weight Tables With Body Mass
Index Tables for Healthy Adults in the United States. Nutrition in Clinical Practice, 21, 312-319.
Calculation for BMI
http://www.mdecg.com/what-is-bmi-and-why-its-important/
Body Mass Index
BMI Classification
BMI range – kg/m2
Risk co-morbidities
<18.5
Low but other risks
18.5 – 24.9
Average
Overweight
25 – 29.9
Mildly increased
Obese Class I
30 – 34.9
Moderate
Obese Class II
35 – 39.9
Severe
Obese Class III
> 40
Very Severe
Category
Underweight
Normal
Bray, G. (1998). What is Ideal Body Weight? Journal Nutrition Biochemistry, 9, 489-492.
BMI Chart
Comparison of Metropolitan Tables
with Body Mass Index
Height in
inch/cm
Metropolitan Metropolitan BMI 20 BMI 22
table (1959)
table (1983) kg/m2 kg/m2
Men Women Men Women
57/144.8
45.36
50.80
58/147.3
46.72
51.71
59/149.9
48.08
52.84 44.9 49.4
60/152.4
49.44
53.98 46.5 51.1
61/154.9
52.84
50.80 59.42 55.34
Height in Metropolitan
table
Metropolitan
table 48.0
BMI 52.8
20
62/157.5 54.43 52.39 60.33 56.70 49.6 54.5
inch/cm
(1959)
(1983)
kg/m2
63/160.0 55.79 53.98 61.24 58.06 51.2 56.3
57.15 Men
56.02 62.37
59.42 52.9 58.1
Men 64/162.6
Women
Women
65/165.1 58.74 57.83 63.50 60.78 54.5 59.9
59.65 64.8662.14
62.14 56.256.2
61.8
66/167.6 60.56 66/167.6
59.6560.56 64.86
67/170.2 62.60 61.46 66.23 63.50 57.9 63.7
68/172.7 64.41 63.28 67.59 64.86 59.7 65.6
69/175.3 66.23 65.09 68.95 66.23 61.4 67.5
70/177.8 68.27 66.91 70.31 67.59 63.2 69.5
71/180.3 70.31
71.90 68.95 65.0 71.5
72/182.9 73.48
73.48
66.9 73.5
73/185.4 74.39
75.30
68.8 75.6
74/188.0 76.66
76.88
70.7 77.7
75/190.5 78.93
78.93
72.6 79.8
BMI 25 BMI 30
kg/m2 kg/m2
56.1
67.4
58.1
69.7
60.0
72.0
BMI 22
62.0
2
kg/m74.4
64.0
76.8
66.1
79.3
68.1
81.8
70.3
61.884.3
72.4
86.9
74.6
89.5
76.8
92.1
79.0
94.8
81.3
97.6
83.6 100.3
86.0 103.1
88.3 106.0
90.7 108.9
Shah, B. (2006). Comparison of Ideal Body Weight Equations and Published Height-Weight Tables With Body
Mass Index Tables for Healthy Adults in the United States. Nutrition in Clinical Practice, 21, 312-319.
BMI 25
kg/m2
BMI 30
kg/m2
70.3
84.3
Ideal body weight (IBW)
Men:
IBW=106 pounds (lb) for first 5 ft. + 6 lb for each inch over 5 ft.
Women:
IBW=100 lb for first 5 ft. + 5 lb for each inch over 5 ft.
For individuals under 5 ft.:
Subtract 2 lb for every inch under 5 ft.
Shah, B. (2006). Comparison of Ideal Body Weight Equations and Published Height-Weight Tables With Body Mass Index
Tables for Healthy Adults in the United States. Nutrition in Clinical Practice, 21, 312-319
Weight-Height Indices Predictors
Grady et al. study (1999):
• Body weight measured by body mass index (BMI) and percentage ideal body weight (PIBW)
• Looked at patient gender, age, and etiology of heart disease to see how correlated with BIM
and PIBW
• Conclusion:
• Greatest risk for infection was found in patients who were >140% of IBW.
• Cachexia or obesity preoperatively showed decreased survival in all patients after heart
transplantation.
• Percent ideal body weight appears to be the better predictor of future morbidity and mortality
following heart transplantation.
• Body Weight was not associated with acute rejection after transplant.
Grady, K. (1999). Are Preoperative Obesity and Cachexia Risk Factors for Post Heart Transplant Morbidity and Mortality:
A Multi-institutional Study of Preoperative Weight-Height Indices. The Journal of Heart and Lung Transplantation, 18, 750-763.
140% IBW vs BMI of 30
Difference between 140% IBW and BMI of 30
Female
Height
Male
BMI 30(#) 140% IBW(#) BMI at 140% 140% IBW(#) BMI at 140%
4'10"
145
126
26.3
-
-
5'0"
155
140
27.3
148
28.9
5'2"
165
154
28.1
165
30.2
5'4"
175
168
28.8
182
31.2
5'6"
185
182
29.3
198
32
5'8"
195
196
29.7
215
32.7
5'10"
210
210
28.7
232
33.3
6'0"
220
224
29.8
249
33.7
6'2"
230
238
30.5
266
35
140% IBW vs BMI of 30
Height
BMI 30(#)
5'6"
185
140% IBW(#) BMI at 140% 140% IBW(#) BMI at 140%
182
29.3
198
32
Pros and Cons of using BMI
Pros
- Simple, inexpensive, and noninvasive
- Correlates with future health risks
- Widespread and longstanding
Cons
- Measures excess weight rather than excess body fat
- Does not distinguish between excess fat, muscle, or
bone mass
- Does not provide indication of the distribution of fat
- Does not consider age, gender, and race
www.cdc.gov/obesity/downloads/BMIforPactitioners.pdf.
Should BMI be the only risk criteria?
National Heart, Lung, and Blood Institute recommends
considering:
1) The individual's waist circumference
(because abdominal fat is a predictor of risk for obesity-related diseases).
2) Other risk factors the individual has for diseases and
conditions associated with obesity
Abdominal fat
Risk factor for numerous diseases:
 Cardiovascular disease
 Hypertension
 Stroke
 Non-insulin diabetes
Molarius, A. (1998). Selection of Anthropometric indicators for classification of abdominal fatness-a critical review,
International Journal of Obesity, 22, 719-727.
Who is greater risk for other
co-morbidities?
Waist circumference
National Institute of Health reported high waist circumference is
associated with an increased risk for type 2 diabetes, dyslipidemia,
hypertension, and CVD in patients with a BMI between 25 and 34.9
kg/m2
Retelny, V. (2008). Nutrition Protocols for the Prevention of Cardiovascular Disease.
Nutrition in Clinical Practice, 23, 468-475.
Changes in
Waist Circumference

Monitoring changes in waist circumference over
time may be an estimate of increased abdominal
fat even in the absence of a change in BMI.

In obese patients with metabolic complications,
changes in waist circumference are useful
predictors of changes in CVD risk factors.
Waist Circumference
Measurement Errors
Correct
Waist Circumference Measuring
Locate upper hip bone and the top of the
right iliac crest.
Place measuring tape around the
abdomen at the level of the iliac crest.
Measurement is made at the end of the
normal expiration.
Tape Position
BMI and Waist Circumference
Waist-to-hip ratio
 1980 Gothenburg and a group from Wisconsin used
waist-to-hip ratio to measure fat distribution.
 Waist circumference measures visceral fat and
abdominal fat.
 The hip measurement may reflect muscle mass, fat
mass, and skeletal frame.
Molarius, A. (1998). Selection of Anthropometric indicators for classification of abdominal fatness
- a critical review. International Journal of Obesity, 22, 719-727.
Waist-to-Hip Ratio Standards
Risk
Men
Women
Ideal
0.8
0.7
Low Risk
<0.90
<0.75
Moderate Risk
0.90 – 1.0
0.75 – 0.85
High Risk
>1.0
>0.85
Bray, G. (1998). What is Ideal Body Weight? Journal of Nutrition Biochemistry, 9, 489-492.
Skin calipers
Skin calipers
Bioelectric Impedance Analysis
Contraindications
The electrical signal is not felt safe for
persons with cardiac pacemakers, and/or
other medical devices implanted in the body.
Underwater weighing
DXA Scan
(Dual X-Ray Absorptiometry)
DXA Scans
Body Fat Percentage Categories
Classification Women (% fat)
Men (% fat)
Athletes
14-20%
6-13%
Normal
14-20%
6-13%
Borderline
31-33%
21-25%
>33%
>25%
Obese
Bray, G. (1998). What is Ideal Body Weight? Journal of Nutrition Biochemistry, 9, 489-492.
Long term outcomes
Cardiovascular events are the leading cause
of mortality after solid organ transplant.
Beckman, S. (2015). Weight gain, overweight and obesity in solid organ transplantation
– a study protocol for systematic literature review. Systematic Reviews, 4, 2.
Prevention of Cardiovascular Disease
♥ Eating patterns and physical activity have roles in
managing weight and CVD risk.
♥ Weight maintenance and obesity prevention is
necessary.
♥ Develop and implement a weight loss/maintenance
program for all individuals above normal weight.
Jensen, M. (2008). Obesity, behavioral lifestyle factors, and risk of acute coronary events.
Circulation, 117, 3062-3069.
What programs may help?
 Collaborate with Clinical Nutritionist
 Nutrition counseling pre and post
transplantation
 Telephone consulting
 Internet technology for behavioral weight
loss program
Clinical Nutritionist
• Trained/experienced in Nutrition for
transplant
• Nutrition Assessment
• Nutrition Interventions
• Nutrition Recommendations
Telephone Consulting
• Increase patient’s knowledge and
understanding
• Enhance success
• Social support-empathy
• Social reinforcement-praise for adherence
• Awareness of discrepancies between
personal goals and actual performance
Sacco, W. P. (2009). Effect of a brief, regular telephone intervention by paraprofessionals for type 2 diabetes.
Journal of Behavioral Medicine, 32, 349-359.
Internet technology
•
Structured behavioral treatment program
•
Weekly contact
•
Individualized feedback
Tate, D. F. (2001). Using Internet technology to deliver a behavioral weight loss program.
Journal of the American Medical Association, 285, 1172- 1177.
Staff and Programs
• Nutritionist on each transplant team
• Hospital programs
• Community programs
Trends in Transplantation
 Obesity is more prevalent and increasing
 Decrease in organ donation (need best candidates)
 Increase in evaluating and accepting obese candidates
 Obesity is a risk factor but what level of obesity causes
adverse outcomes?
Conclusion
 Monitor level of obesity in each organ
transplantation group, outcomes, treatment
regimen, and donor pool.
 Set defined weight criteria for each organ.
 Use another criteria along with BMI.
 Determine which weight loss programs are
effective.
Hasse, J. (2007). Pretransplant Obesity: A Weighty Issue Affecting Transplant Candidacy and Outcomes.
Nutrition in Clinical Practice, 22, 494-504.
References
• Beckman, S. (2015). Weight gain, overweight and obesity in solid organ transplantation –a study protocol for
systematic literature review. Systematic Reviews, 4, 2.
• Bray, G. (1998). What is Ideal Body Weight? Journal of Nutrition Biochemistry, 9, 489-492.
• Grady, K. (1999). Are Preoperative Obesity and Cachexia Risk Factors for Post Heart Transplant Morbidity and
Mortality: A Multi-Institutional Study of Preoperative Weight-Height Indices. The Journal of Heart and Lung
Transplantation, 18, 750-763.
• Hasse, J. (2007). Pretransplant Obesity: A Weighty Issue Affecting Transplant Candidacy and Outcomes. Nutrition in
Clinical Practice, 22, 494-504.
• Jensen, M. (2008). Obesity, behavioral lifestyle factors, and risk of acute coronary events. Circulation., 117, 30623069.
• Milaniak, I. (2014). Post-Transplantation Body Mass Index in Heart Transplant Recipients: Determinants and
Consequences. Transplantation Proceedings, 46, 2844-2847. http://dx.doi.org/10.1016/j.transproceed.2014.09.025
• Molarius, A. (1998). Selection of Anthropometric indicators for classification of abdominal fatness-a critical review.
International Journal of Obesity, 22, 719-727.
• Retelny, V. (2008). Nutrition Protocols for the Prevention of Cardiovascular Disease. Nutrition in Clinical Practice, 23,
468-475.
• Sacco, W. P. (2009). Effect of a brief, regular telephone intervention by paraprofessionals for type 2 diabetes. Journal
of Behavioral Medicine, 32, 349-359.
• Shah, B. (2006). Comparison of Ideal Body Weight Equations and Published Height-Weight Tables With Body Mass
Index Tables for Healthy Adults in the United States. Nutrition in Clinical Practice, 21, 312-319.
• Tate, D. F. (2001). Using Internet technology to deliver a behavioral weight loss program. Journal of the American
Medical Association, 285, 1172-1177.
• www.cdc.gov/obesity/downloads/BMIforPactitioners.pdf. (n.d.).