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Fuzzy Obesity Index for Obesity Treatment and Surgical Indication

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Fuzzy Obesity Index for Obesity Treatment and Surgical Indication
Susana Abe Miyahira, Ernesto Araujo, Member, IEEE
Abstract— A Fuzzy Obesity Index for being used as an
alternative in obesity treatment and bariatric surgery indication
(BSI) is presented in this paper. Obesity is nowadays understood
as universal epidemy and became an important source of death
and co-morbidities. The search for a more accurate method to
evaluate obesity and to indicate a better treatment is important
in the world health context. In this paper the Body Mass
Index (BMI) is first modified and treated as fuzzy sets. BMI is
characterized by its capacity of weight excess and considered the
main criteria for obesity treatment and BSI. Nevertheless, the
fat excess related to the Body Fat (BF) is actually the principal
harmful factor in obesity disease, that is usually neglected. Due
to that this paper also presents a new fuzzy mechanism for
evaluating obesity by associating BMI with Body Fat (BF) that
yields a fuzzy obesity index for obesity evaluation and treatment
and allows to build up a Fuzzy Decision Support System (FDSS)
for BSI. Different values of BMI and BF (in terms of %BF)
used for validating the proposed method classify individuals in
distinct categories with degrees of compatibility more realistic
than those accomplished by Boolean classification, as usually
occur. The proposed method may assume an important whole
in medicine as an index for obesity evaluation and surgery
treatment by using the advantages of BMI and BF in synergy.
I. I NTRODUCTION
T HE clinical condition known as obesity currently as-
sumes the characteristic of universal epidemy. This
syndrome is important cause of death and related diseases
(also denominate co-morbidities). Moreover, it directly and
proportionally corresponds to the magnitude of the obesity
clinical condition [1], [2], [3], [4]. Nevertheless, the obesity
definition, measurement, classification and treatment are not
easily determined. Finding out a mechanism for obesity eval-
uation and level classification, mainly if concerned with risks
or prescription of treatments, bariatric surgery indication
(BSI) etc., is of great clinical interests.
Effort have been spent to classify what is overweight,
obesity etc. by using diverse anthropometric parameters when
the interest is to determine the best therapeutic indication and
treatment as well as the best appropriate mechanism for data
Susana Miyahira is both with the Anesthesiology Dpt., Hospital Munic-
ipal Dr. Jose de Carvalho Florence, Av. Saigiro Nakamura, 800, 04023-
062, Sao Jose dos Campos, SP, Brazil and with Universidade Federal de
Sao Paulo (UNIFESP), R. Botucatu, 862, 04023-062, Sao Paulo, SP, Brazil
(email: susana miyahira@uol.com.br).
Ernesto Araujo is with Computer Science / Health Informatics Depart-
ment (DIS), Universidade Federal de Sao Paulo (UNIFESP), R. Botucatu,
862, 04023-062, Sao Paulo, SP, Brazil (email: ernesto.araujo@unifesp.br),
with Integration and Testing Laboratory (LIT), Instituto Nacional de
Pesquisas Espaciais (INPE), Av. Astronautas, 1758, 12.227-010, (email:
ernesto.araujo@lit.inpe.br), and with the Hospital Municipal Dr. Jose de
Carvalho Florence, Av. Saigiro Nakamura, 800, 04023-062, both in Sao
Jose dos Campos, SP, Brazil.
2392
978-1-4244-1819-0/08/$25.002008
c IEEE
analysis. The search for a more accurate method to evaluate
obesity and, consequently, the better treatment, motivate the
proposition of a new index for surgical treatment and for a
novel classification for obesity and the classes correlated to
it. A novel Fuzzy Obesity Index is proposed for being used
as an alternative in obesity treatment and BSI, as well.
The fuzzy set theory and fuzzy logic related to the
approximate reasoning is the theory of classes with fuzzy
borders and they present great appeal in the real world,
being of special interest to biosciences. Update publications
demonstrate the progressive growing in the use of fuzzy
logic in diverse medical areas such as internal medicine,
cardiology, vascular surgery, orthopedy, anesthesiology, der-
matology, ophthalmology, otorrinolaringology, gynecology,
urology, neurology, pathology, biochemistry, pharmacology
and genetics [5]. These characteristics associated to the
capacity to deal with linguistic variables and linguistic terms
making easy the understanding of operators and users, the
low computational cost and the ability to incorporate the
expertise of specialists justify the growing number of tech-
nical papers applied to the fuzzy sets theory and fuzzy
logic in biomedical questions. Due to that this mathematical
approach has become an interesting option to elaborate
medical models, be it for diagnose systems, medical image
treatment, public health or epidemiology, only to mention
few [6], [7], [8], [9], [10], [11], [12], [13], [14].
The first main contribution of this proposal is to modify
the Body Mass Index (BMI) by treating the crisp classes
usually adopted by the World Health Organization (WHO) to
fuzzy sets. Although the BMI is the most known mechanism
employed for classify obesity, there is a consensus concerned
the gravity that pathological condition of the chronic obesity
disease assumes is directly proportional to fat accumulation
in the body – Body Fat (%BF). This fuzzification proceeding
is extended to %BF classes. In so doing, diverse values for
BMI and %BF classify individuals in different categories
with more realistic degrees of compatibility when compared
with those indexes for obesity evaluation and surgical treat-
ment with Boolean classification as usually utilized. After-
wards, the BMI and %BF classes are aggregated yielding a
new index. This new index uses the advantage of the old
methods and aims to compensate the disadvantage of them.
If as for input linguistic variable are considered the BMI and
%BF in which the universe of discourse is parted by using
fuzzy sets, as output linguistic variable is employed a obesity
classification with entirely new classes of obesity in the fuzzy
context as well as is used for BSI. The final contribution of
this paper is to use the new fuzzy mechanism for getting
together BMI and Body Fat (BF) for building up a Fuzzy
Decision Support System (FDSS) for surgery indication.

II. M ECHANISMS FOR B ODY M ASS E VALUATION
The Body Mass Index (BMI), also denominate Quetelet
index [15], is a grade system for classify obesity by us-
ing a mathematical relation of proportionality given by
IMC = P/H 2 , where the body weight, P , of the individual
is given in Kilograms [Kg] and the square of the height, H,
express in square meters, [m2 ]. The distinct classes of BMI
for identification, evaluation and treatment of overweight
(ow) and obesity in adults is presented in Table I.
The BMI is an international index used in epidemiological
studies and it is the most known mechanism for classifying
obesity and determining obesity treatment or BSI. According
to the BMI and comorbidities, the BSI classification is given
in Table II. This index, however, presents severe limitations.
The main disadvantage of BMI is that the actual body
composition is not taken into account. The estimate excess
of weight may occur both by increasing the fat tissue and
by the muscular hypertrophy. In this sense, a person with
BMI with a index of 30 may be classified in the obese
group and be erroneously classified as overweight. In the
counterclock direction, a physiculturist with an usual low
percentage of body fat – for instance, 9.3 – may also be
erroneously classified as overweight if only if it is assumed
the BMI as the unique way of obesity measurement. Another
disadvantage is also the use of height as a main parameter
of analysis due to its incorrectness and modification in the
body structure. Consider, for instance, when the patient
presents anatomical alteration in backbone by having its
height decreased, as it happens to old people. In this case,
the BMI gives an inappropriate value, more elevated than the
actual due to the bend of the backbone that usually occur with
old people or presenting a health backbone problem. This
problem is also extended to people that present low height
due to some hormonal problem. Moreover, momentaneous or
periodic weight modification such as those of weight raise
in menstrual period may result in an artificial elevated BMI,
influencing the final classification. Finally, the BMI does not
point out the body fat and becomes, thus, an restrict method
for evaluating obesity and for BSI.
If for one side, the determination of BMI is a mechanism
to help in determining the excess of weight world wide
known, for other side, the BF measurement presents a greater
importance than the simpler measurement of the global
body weight. The main harmful factor in obesity is the BF
TABLE I
C LINICAL GUIDELINES ON THE IDENTIFICATION , EVALUATION AND
TREATMENT OF OVERWEIGHT AND OBESITY IN ADULTS .
Classification of Overweight Obesity Class BMI (Kg/m2 )
Underweight (UW) – < 18, 4
Thin – 18,5 to 24,9
Overweight (OW) – 25 to 29,9
Obesity (OI) Grade I 30,0 to 34,9
Obesity (OII) Grade II 35,0 to 39,9
Morbid Obesity (OIII) Grade III ≥ 40
(Source: WHO - World Health Organization)
2008 IEEE International Conference on Fuzzy Systems (FUZZ 2008)
TABLE II
BARIATRIC SURGERY INDICATION (BSI) ACCORDING TO B ODY M ASS
I NDEX (BMI) AND COMORBIDITIES .
35 < BM I < 39 BM I > 40
Without Comorbidities No Surgery Surgery
With Comorbidities Surgery Surgery
accumulation and not the fat free mass that does not affect the
health of the patient [16], [17], [18], [19], [20]. Additionally,
the BMI reveals itself a imprecise method and low accuracy
for measure BF in distinct physical classifications. Despite
these limitations, the BMI is employed to indicate obesity
treatment all over the world and surgical treatment [21], [22].
There are distinct methods for BF evaluation such as, for
instance, SkinFold Thickness (SKF), Densitometry (Hydro-
static Weight), Dual-Energy X-ray Absorptiometry (DEXA),
Bioelectrical Impedance Analysis (BIA). Each of them
presents inherent advantages and disadvantages. However,
all of them demonstrate good correlation among themselves,
thus, justifying their use interchangeably.
The %BF is considered a better index for evaluate obesity
than BMI since the latter only works as an indicative of
weight excess and the first one is an indicative of excess of
fat mass and the risk of keep being obese (Table III). Thus,
it seems that the %BF has being underexploited and so it
should be investigated to evaluate the surgical treatment.
There is, however, no consistent information in the litera-
ture presenting which is the distributed %BF in the organism
that corresponds to the BMI, nor if it is compatible with
the prescription of surgical treatment. Neither there is a
degree of %BF that would correspond to the development
of comorbidies that are associate to the obesity disease. In
order to introduce a consistent mechanism for dealing with
obesity in this paper both BMI and %BF are put together
to present a new obesity index by employing fuzzy sets and
fuzzy logic theory.
III. F UZZY O BESITY I NDEX
Nowadays, the obesity classification and indication of
surgical treatment, for example, with BMI is accomplished
by using classic (Aristotelic) sets theory, in which the values
belongs to a set, or not (Fig. 1). In these sets an element, xi ,
is a member of the universe of discourse, X, associated to
the linguistic variable BMI such that X = {x1 , . . . , xn |xi ∈
BMI} and assumes a unitary value, μ(xi ) = {1}, for each
element that belongs to the set or a null value, μ(xi ) = {0},
TABLE III
C LASSIFICATION OF OVERWEIGHT AND O BESITY BY %BF
Obesity Women Men
Adequate (AF) < 25 % < 15 %
Low (LF) 25–30 % 15–20 %
Moderate (MOD) 30–35 % 20–25 %
Elevate (ELEV) 35–40 % 25–30 %
Morbid (MOR) > 40 % > 30 %
2393
 Fig. 1. Body Mass Index (BMI) as Crisp Classes.
(a) Fuzzy Membership Functions for Body Mass Index (BMI).

for each element that does not belong to the set. The same
proceeding is extended to %BF. Nevertheless, it seems a
mistake to attribute a Boolean classification as the one for
BMI and %BF. Consider, for instance, a patient with BMI =
39 and other patient with BMI = 40. According to the WHO,
these patients are classified in distinct groups, respectively,
Obesity II and Obesity III and presenting different indications
of treatment. While the first patient is out of the range of
surgical treatment, the second one is classified for treatment
even if the variation of the patients is minimal, i.e., from
BMI = 39 to BMI = 40 the variation is only ΔBMI = 1.
Usually, in these cases, both patients do not present signifi-
cant biological, anatomical, or physiopathological differences
that justify discrepancies in the indication of BSI with a (b) Fuzzy Membership Functions for Body Fat (%BF).
minimal variation, ΔBMI, as mentioned.
Fig. 2. Input Linguistic Variable for Fuzzy Obesity Index
The implementation of the proposed fuzzy obesity index
employs fuzzy grade of the values found in the BMI and
%BF and uses the logic operation of conjunction between
their partial values and linguistic terms. The obesity is, then,
given by the set of ordered pair, (x, y), such that the first
element is the member of the universe of discourse, X,
associated to the linguistic variable BMI and the second
one is member of the universe of discourse, Y , related to
linguistic variable %BF, yielding a Cartesian product in the
form , X × Y = {(x, y)|x ∈ X, y ∈ Y }, such that X =
{x1 , . . . , xn |xi ∈ BMI} and Y = {y1 , . . . , yn |yj ∈ %BF}.
Since in classical set theory the parting of the universe of
discourse is such that the ordered pair assumes either a Fig. 3. Output Linguistic Variable for Fuzzy Obesity Index
unitary value, (x, y) = 1, for each pair that belongs to the
relation or a null value, (x, y) = 0, for each par that does not
belong to the relation, i.e., μ(x,y) = {0, 1}, it seems to be classified as OII and OIII in the same time. The difference
more appropriate to part the universe of discourse of BMI and now exists in the fact that the first patient is classified in the
%BF by using the fuzzy set theory. In doing so, each ordered OIII group with a degree of activation higher than that one
pair, (x, y) assumes an intermediary value between 0 and 1, in the OII group – the contrary is true for the second patient.
i.e., μ(x,y) = [0, 1], being able to yield an overlapping of The use of fuzzy sets theory and fuzzy sets allows a patient
classes. The patient can now be classified in complementary with BMI = 39kg/m2 be classified according to the use of
and distinct manners as depicted in Fig. 2(a) and Fig. 2(b). fuzzy sets in the group of surgical treatment with a degree
The advantage of using fuzzy sets for classes of BMI and of pertinence concurrently being in the group of no surgical
%BF is that, following the same example used before, the indication but with another degree of pertinence. Moreover,
patients with BMI = 39 and BMI = 40 are both to be both patients would be able to be indicate to BSI, or not, for

2394 2008 IEEE International Conference on Fuzzy Systems (FUZZ 2008)

example, depending on additional factors and not exclusively
related to BMI as currently accomplished. Due to that, the
fuzzy approach allows to each patient to be classified in a
compatible manner with the various available categories but
with different degrees of pertinence with the advantage of
considering the more realistic classification for BSI related
to the variables of analysis employed.
The fuzzy logic has its core based on inference rules.
This fuzzy inference mechanism uses the logical principles to
determine how facts and rules must be combined to derive
other facts. An important concept is the fuzzy conditional
proposition. When dealing with two inputs and one output –
as it is the case in this paper – it assumes the form, IF: < x
is A > AND < y is B > THEN < z is C >, where x and
y are input linguistic variables, A and B are input linguistic
terms, z is the output linguistic variable, and C is the output
linguistic term. The terms (x is A) and (y is B) form the
antecedent while (z is C), the consequent of the rule. In
this paper, the input linguistic variables are the BMI and
%BF. The output linguistic variable is the obesity evaluation
and its correlated to BSI. This relationship is associate to
the estimative of obesity (input) and obesity classification or
BSI (output).
A. Preliminary Parameters of the Fuzzy Obesity Index
A fuzzy set, A, in the universe of discourse BMI is
defined as a membership function, μA (x), mapping each
element to a number (degree) in the interval [0, 1]. This
membership function, μA (x), can be understood as de degree
of compatibility for the linguistic terms. Thus, the proposed
fuzzy obesity index establish an arbitrary value in the interval
of [0, 1] yielding a graduated and smooth surface in the
classification of BMI. The BMI input linguistic variable was
built up based on World Health Organization (WHO) as
shown in Table I. The linguistic terms for parting the universe
of discourse are lower weight (LW), thin (T), overweight
(OW), Obesity grade I (OI), Obesity grade II (OII), and
Obesity grade III (OIII). In doing so, the elements, xi , of the
universe of discourse BMI are distributed in the universe of
discourse, X, and grouped and labeled as classes or linguistic
terms as BMI = {LW, T, OW, OI, OII, OIII} (Fig. 2(a)).
When building the %BF input linguistic variable, new
overweight and obesity values were adapted from Ta-
ble III and the selected linguistic terms are adequate
fat (AF), low fat(LF), moderate (MOD), elevate (ELEV)
and morbid (MOR). The elements, yi , of %BF, are dis-
tributed in the universe of discourse, Y , and grouped and
TABLE IV
F UZZY M ATRIX FOR O BESITY C LASSIFICATION
UW T OW OI OII OIII
AF CDE TH MUH MUH MUH X
LF X TH MUH MUH MUH X
MOD X EW EW SUT SUT MOB
ELEV X EW FZOB FZOB FZOB MOB
MOR X X FZOB FZOB MOB MOB
2008 IEEE International Conference on Fuzzy Systems (FUZZ 2008)
Fig. 4. Porcentage of Body Fat (%BF) as proposed Fuzzy Membership
Functions.
labeled as classes or linguistic terms, for example, as
%BF = {AF, LF, MOD, ELEV, MOR} (Fig. 2(b)).
The output in the consequent of the rule is given by obesity
evaluation also related to BSI (consequent of the rule). The
set of linguistic terms are chronic deficit of energy (CDE),
Thin (TH), muscular hypertrophy (MUH), excess of weight
(EW), sutomori (SUT), fuzzy obesity (FZOB), morbid obe-
sity (MOB). The output linguistic variable for obesity index
or BSI is given in Fig. 3.The elements, zi , of %BF, are
distributed in the universe of discourse, Z, and grouped
and labeled as classes or linguistic terms, for example,
as Obesity = {CDE, TH, MUH, EW, SUT, FZOB, MOB}
(Fig. 3). The sutomori fuzzy set for obesity is introduced
by the authors an there is no similar in literature. The sumo
wrestlers are classified apart of the other categories since they
present unique characteristics. These athletes have a muscular
mass and presents a high level of %BF and due to that are
usually considered as obese. However, when compared with
individuals with equivalent BMI, they present lower values
of %BF.
In order to find out a mechanism of classification that takes
into account the advantage of distinct method already em-
ployed but working in synergy to suppress their disadvantage,
here, the BMI and %BF are combined by using the fuzzy
sets and fuzzy logic and form the premises related to the
antecedent of the rule. The rules for the base of knowledge
is given according to the fuzzy matrix presented in Table IV.
The rules herewith are restrict to those relevant and actual
to life existence as well as practical occurrence, so, some
possible rules are not taken into account. In this paper, obese
for BSI are considered those into FZOB class in conjunction
with comorbidities and those classified as MOB, independent
of the presence of comorbidities. The mapping surface for
the fuzzy model related to the new obesity index and surgical
treatment is depicted in Fig. 4.
The inference mechanism for decision-making chosen is
the Mamdani approach. The defuzzification method is the
2395
 TABLE V
C OMPARATIVE E XAMPLES OF B ODY M ASS I NDEX (BMI), B ODY FAT (%BF) AND M IYAHIRA -A RAUJO F UZZY O BESITY I NDEX (MAFOI)

Classification (Men) BMI Crisp Fuzz %BF Crisp Fuzz MAFOI∗

1 Control [35] 20.48 T UW, T 12.9 LF AF,LF 14.2 TH
2 Body building [36] 26.32 OW T, EW 9.3 AF AF 17.6 MUH
3 Sarcopenic Obesity [37] 24.00 T T, EW 19.9 LF LF,MOD 20.2 EW
4 USA Men [38] 34.30 OI OI, OII 34.7 MOR MOR 28 FZOB
5 GrH Treated [39] 39.20 OII OII, OIII 28 ELEV ELEV, MOR 29 FZOB
6 Sumo Wrestlers [40] 36.50 OII OI, OII 26.5 ELEV ELEV, MOR 28.1 SUT
7 Sumo Wrestlers [41] 36.84 OII OI, OII 29.6 MOR ELEV, MOR 27.9 SUT
8 Control Sumo Wrestlers [41] 36.50 OII OI, OII 35.4 MOR MOR 31.8 MOB

center of area. It is worthing mentioning that prevents the use
of other inference mechanisms and defuzzification methods.
IV. A NALYSIS AND I LLUSTRATIVE E XAMPLES
At the upper extreme of the bidimensional graphic in Fig. 4
there is no difference when using the proposed method or
the classical approaches. Nevertheless, in the intermediary
regions the fuzzy obesity index shows its value since it allows
to represent degrees of composed obesity when using two
important indexes in medicine – BMI and %BF – that was
not possible before without employing fuzzy set theory.
Although not being the focus of this paper, another region
that is worth to point out is the inferior part of the Cartesian
product (fuzzy obesity index) labeled CDE. It indicates
a mathematical and formal mechanism for represent and
understand anorexy.
It is also important to mention that when the %BF is in the
lower limit this obesity indicative is more important than the
BMI and the latter would be disconsidered, however, being
important in the other regions. The HMU class means that
there is an increasing weight due to muscular mass and not
to fat excess.
There is overlapping classification of EW, SUT, and
FZOB, however, the sumo wrestlers (SUT) are put apart
since they present special characteristics. These athletes have
weight increasing both in muscular mass as also of body fat
and may be classified as obese in the EW category. However,
when compared with individuals with BMI equivalents, they
have lower %BF, present physiological adaptation, and do
not present commorbities. Such a fact can be noticed in the
examples 4 and 7 in the illustrative examples of table V
for what the values obtained with the proposed MAFOI are
coincident for both groups of analysis.
In order to validate the fuzzy obesity model proposed, this
paper selected different obesity evaluations in the Medline
and Medscape Data Base for analyzing both BMI and %BF.
Since the proposed fuzzy obesity index can interchangeably
be employed with all of the other BF measurements. The
%BF values obtained with SkinFold Thickness (SKF), Den-
sitometry (Hydrostatic Weight), Dual-Energy X-ray Absorp-
tiometry (DEXA), as well. These data are compared and
analysed as shown in Table V according to literature [35],
[36], [37], [38], [39], [40], [41].
This paper, initially, uses data of men population, further
paper will consider women and children, as well. For in-
stance, in another example 8 in table V, the MAFOI indicates
MOB. According to the set of rules and the membership the
output value is 31.8 and absolutely indicates a obesity for
bariatric surgical indication. In the examples 4 and 5, the
MAFOI is FZOB with obesity value of 29 meaning that
there is BSI only in the presence of some commorbities.
Other examples can directly be observed in table V.
Results indicate a gradual, smooth obesity classification
and BSI when using the proposed fuzzy obesity index when
compared with other traditional methods for dealing with
obesity.
V. C ONCLUSIONS
The use of fuzzy sets and fuzzy logic allows the conception
of a new model for obesity classification were individuals
were classified in distinct categories according to conjunct
fuzzy values of Body Mass Index (BMI) and Porcentage of
Body Fat (%BF) in a gradual, smooth and complementary
manner. In this way, this paper preconize a novel index that
relate the obesity indicators previously known in literature,
in particular, the BMI and %BF by using fuzzy sets and
fuzzy logic, making them work in synergy instead of in a
conflicting, competitive manner.
The original approach herewith is more realistic and ap-
propriate to the practical necessities to obesity classification
as well as indication of bariatric surgery.
This study conclude that the BMI is not adequate for
surgical indication in all the conditions and that the fuzzy set
theory and fuzzy logic become an alternative for decision-
making in bariatric surgery indication based on the Miyahira–
Araujo Fuzzy Obesity Index (MAFOI). The novel index can
assume an important whole in medicine by changing the way
obesity is perceived and treated.
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