1. health and fitness
2. disease
3. diabetes

1 :4
Is India really getting fatter- Urban Rural Divide?
How to Manage Obesity?
Weight control is a journey, not a
destination
The second half of the twentieth century witnessed major
health transitions in the world, propelled by socio-economic and
technological changes which profoundly altered life expectancy
and ways of living while creating an unprecedented human
capacity to use science to both prolong and enhance life. Dietary
deficits and excesses and the lifestyle changes that accompany
industrialization and urbanization with economic development
make a significant contribution to the most globally pervasive
change of the rising burden of obesity and non-communicable
diseases (NCDs).
Obesity was identified as a disease thirty years ago when, the
World Health Organization (WHO) listed obesity as a disease
condition in its International Classification of Diseases in 1979.
Analysis of mortality trends suggests that large increases in NCDs
have occurred in developing countries, particularly those in rapid
transition (e.g. Brazil, china and India.).1 The epidemic of rapid
nutrition transition and its adverse health consequences in the
Asian region are now beginning to get noticed.These include insulin
resistance, type 2 diabetes, hypertension, coronary artery disease,
hyperlipidemia, metabolic syndrome (Syndrome X), stroke and
certain cancers. Mortality from cardiovascular disease is expected
to rise by about 60%, and overtake deaths from infectious diseases
by 2015-2020.The prevalence of type 2 diabetes has increased by
40% in Chennai between 1988 and 1994. It is predicted that the
prevalence of type 2 diabetes will rise from 4% to 5.4% by 2025,
and the proportional rise will be greatest in developing countries
(48%), especially India (59%). India will have more people with
diabetes (~ 57 million), than any other country, with the greatest
numbers in the 45-64 years age group. The economic and health
consequences of obesity epidemic can spell disaster for the nation
unless immediate remedial measures are instituted.2 The complex
range of factors that interact to determine the nature and course
of obesity epidemic needs to be understood in order to adopt
preventive strategies to help developing societies like India deal
with this burgeoning problem.
What is Obesity?
Obesity is a state of excess adipose tissue mass that
Vitull K Gupta, Sonia Gupta, Bhatinda
imparts health risk. (20% more than Ideal Body Weight).
Lean but very muscular individuals may be overweight by arbitrary
standards without having increased adiposity. Obesity is effectively
defined by assessing its linkage to morbidity or mortality.
Methods to calculate obesity
Body Mass Index (BMI): weight in Kg / height in meter 2 (kg/
m2), skin-fold thickness, Densitometry (underwater weighing),
Computed tomography (CT) or MRI,Waist to Hip Ratio (Central
Obesity), Ideal Body Weight (Kg) = {(Height in cm-100) X 0.9}.
Body Mass Index (BMI): BMI is recommended as a practical
approach for assessing body fat in the clinical setting. It provides
a more accurate measure of total body fat compared with
the assessment of body weight alone.3 The typical body
weight tables are based on mortality outcomes, and they do
not necessarily predict morbidity. However, BMI has some
limitations. For example, BMI overestimates body fat in persons
who are very muscular, and it can underestimate body fat in
persons who have lost muscle mass (e.g., many elderly).
Classification of BMI:4 5
•
Underweight (<18.5Kg/m2).{ Mildly thin (17.0- 18.4Kg/m2)
Moderately/ severely thin (<17.0 Kg/m2) }
•
Normal (18.5-24.9 Kg/m2).
•
Overweight (25-29.9kg/m2)
•
Obese (30- 34.9 Kg/m2).
•
Sever Obesity ( 35- 39.9Kg/m2)
•
Morbid Obesity (>40Kg/m2)
Several studies from India have attempted to modify the
threshold for obesity and abdominal obesity using various
metabolic abnormalities as gold standard. These studies have
suggested cut-off for BMI ranging from 19-22Kg/m2 while
that of waist circumference ranges from 72-85cm in men and
Medicine Update 2010  Vol. 20
65.5-80 cm in women.6 Several reports suggest that for any
given BMI, Indians tend to have increased waist circumference.
Further Indians also tend to have excess body fat, abdominal
and truncal adiposity. For any given waist circumference, Indians
have increased body fat accumulation and for any given body fat,
Indians have increased insulin resistance.7 8 These features have
been referred to as the “Asian Indian Phenotype or Paradox”.9.
The WHO has revised the BMI cut-off for Asian Indians and
suggested a BMI of 25kg/m2 to define obesity against the 30kg/
m2 recommended for Europeans.10
men with lowest wealth index, prevalence of obesity was 1.4% and
23.6% among men with highest wealth index. (Tabl e: 1).
Available data on prevalence of obesity from different published
studies suggest that the prevalence ranged from 10 to 50 %.6 There
are several reports from various parts of India mostly urban which
provide some insight into the problem. A study from Bombay
revealed the prevalence of obesity among young adult males
varied from 10.7% to 53.1%.16 A report from Kashmir showed
prevalence of obesity to be 15.0%, with 23.7% females and 7%
males.17 .A report from Nutrition Foundation of India Suggested
that the prevalence of obesity varies with socio economic status
in urban India, with those in upper strata having higher prevalence
rates (32.2% among males, 50% among females) than middle class
(16.2% among males, 30.3% among females) followed by the lower
socio economic group (7% among males, 27.8% among females)
and the poor in urban slums with the lowest (1% among males, 4%
among females).18 In a study by Reddy, et al., more than 28% of adult
males and 47% of adult females in urban Delhi were overweight
by WHO standards.19 In the same study the corresponding figures
for overweight in a neighboring Haryana rural area were 7% in
males and 9% in females. Conversely, as many as 38% of males
and 36% of females in the rural area were actually ‘underweight’
by BMI standards. A study from Punjab by Vitull et al concluded
that prevalence of overweight was 5.1% in males and 3.4% in
females and the prevalence of obesity in males was 0.3% and
0.4% in females was recorded in rural population which is quite
less than that of prevalence reported in several urban studies.20
NFHS -3 data also reveal the extent of underweight population
both male and female population which was more in rural and
poor population. (Table: 2) Such an ‘urban, rural divide’ has been
documented in other Indian studies too.21 The prevalence of
underweight or malnutrition is really disturbing giving arises to
double nutritional burden on Indians of obesity on one hand and
malnutrition on the other.
Is India really getting fatter- Urban
Rural Divide?
The prevalence of obesity is increasing world wide. Data from the
National Health and Nutrition Examination Surveys (NHANES)
show that the percent of the American adult population with
obesity (BMI > 30) has increased from 14.5% (between 1976
and 1980) to 30.5% (between 1999 and 2000). As many as 64%
of U.S. adults 20 years of age were overweight (defined as BMI
> 25) between the years of 1999 and 2000. Extreme obesity
(BMI 40) has also increased and affects 4.7% of the population.11
As a Consequence of rapid industrialization and urbanization
leading to rise in living standards, prevalence of obesity is rapidly
rising posing a greater threat to health of Indian nation. Obesity
has reached epidemic proportions in India in the 21st century,
affecting 5% of the country’s population.12 India is following a trend
of other developing countries that are steadily becoming more
obese and is currently experiencing an increase obesity epidemic.
In 1990’s National Nutrition Monitoring Bureau documented the
prevalence of obesity in Indian women to be 4.1% and National
Family Health Survey -2 13(NFHS-2) reported obesity prevalence
rates ranging from 3.5% to 4.1%. National Family Health Survey-3
(NFHS-3)5 reviled obesity as a substantial problem among several
groups of women in India particularly older women, urban, well
educated, women from households with high standard of living
and among Sikhs. Data from NFHS-3 showed that 12.6% of Indian
women were obese (23.5% urban and 7.4% rural). Among men
the total prevalence of obesity was 9.7% (15.9% urban and 5.6%
rural).The percentage of ever-married women age 15-49 who are
overweight or obese increased from 11% in NFHS-2 to 15% in
NFHS-3.The percentage of women who are overweight or obese
is highest in Punjab (30%), followed by Kerala (28%) and Delhi
(26%). Similar variations are seen by state in the percentage of men
who are overweight and obese. Further analysis of data showed
that out of 12.6% obese women 9.8% were overweight (BMI of
25-29.9) and 2.8% were obese (BMI of > 30). Similarly among
9.7% obese men, 8.4% were overweight and 1.3% were obese.
Prevalence of obesity was directly related to the socio economic
status where only 1.8% females with lowest wealth index were
obese as compared to 30.5% in highest wealth index. In NFHS-3
Wealth Index has been classified as lowers, second, middle, fourth
and highest Wealth Index groups according to several parameters
representing family’s socio economic status.14 15 Similarly among
Childhood obesity was considered a problem of affluent countries.
Today the problem is started appearing even in developing
countries. The calculated global prevalence of overweight
(including obesity) in children aged 5-17 years is estimated by the
International Obesity Task Force (IOTF) to be approximately 10%,
but this is ‘unequally distributed’ with prevalence ranging from
over 30% in Americas to <2% in sub Saharan Africa.22 Prevalence
of overweight amongst Australian children has increased from
11% in 1985 to 20% in 1995.4. Childhood obesity has tripled in
Canada in last 20 years. Currently the prevalence of obese school
children is 20% in U K and Australia, 15.8% in Saudi Arabia, 15.6%
in Thailand, 10% in Japan and 7.8% in Iran.23 24
Societies like India, which are rapidly urbanizing, demonstrate
life style changes resulting increase in energy intake, dramatic
increase in fat intake along with increased level of sedentarianism
are encountering increased prevalence of childhood obesity along
with adult obesity. National representative data for childhood
obesity in India is best represented by NFHS -3 data. Three
standard indices of physical growth that describe the nutritional
14
Is India really getting fatter- Urban Rural Divide? How to Manage Obesity?
Table1 5 : Prevalence of obesity among males and females age 15-49 years (in %) (NFHS -3 2005-06)
>25 BMI Obesity
Male
Female
25-29.9 BMI Overweight
Male
Female
> 30 BMI Obese
Male
Female
Residence
Urban
15.9
23.5
13.5
17.4
2.4
6.1
Rural
5.6
7.4
5.0
6.2
0.6
1.3
Lowest
1.4
1.8
1.3
1.6
0.1
0.2
Second
2.2
3.9
1.9
3.4
0.2
0.5
Middle
5.0
7.4
4.6
6.5
0.4
0.9
Fourth
10.2
15.4
9.1
12.5
1.0
2.9
Highest
23.6
30.5
19.6
22.0
4.0
8.4
Total
9.7
12.6
8.4
9.8
1.3
2.8
Wealth Index
Table 2 : Prevalence of Malnutrition among males and females age 15-49 years (in %). (NFHS -3 Data 2005-06)
Residence
Urban
Rural
Wealth Index
Lowest
Second
Middle
Fourth
Highest
Total
<18.5 BMI Underweight
Male
Female
17-18.4 BMI Mildly Thin
Male
Female
<17 BMI Severely thin
Male
Female
26.5
38.4
25%
40.6
15.0
23.4
13.2
22.9
11.5
15.1
11.8
17.8
48.3
42.4
37.4
29.6
19.1
34.2
51.5
46.3
38.3
28.9
18.2
35.6
29.6
25.7
22.1
17.2
11.2
20.4
28.5
25.7
21.1
16.2
10.2
19.7
18.7
16.7
15.3
12.4
7.9
13.8
23.0
20.6
17.3
12.7
8.0
15.8
Table: 3 Prevalence of Malnutrition and obesity
among children under five years of age (in %).
(NFHS -3 Data 2005-06)
status of children are presented in NHFS-3 report are: Heightfor-age (stunting),Weight-for-height (wasting) and Weight-for-age
(underweight). BMI or weight for height index which measures
body weight in relation to body length, describes current
nutritional status in a better way. Children were considered thin
and malnourished if their score was below minus two standard
deviations (< -2SD) from median of the reference population,
severely wasted if score was below minus three standard
deviations (< -3SD) and overweight if score was above plus
two standard deviations (+ 2SD) from median of the reference
population. According to NFHS-3 data 1.7% male children and
1.4% female children were overweight (+ 2SD), 2.5% belonged to
urban and 1.2% belonged to rural areas. Prevalence of childhood
obesity increased with increase in socio economic status of the
family being 1.0% in low wealth index group and 2.7% in high
wealth index group. Conversely NFHS-3 data also reveled greater
prevalence of underweight or malnourished (%age below -3SD
and below -2 SD) child population which was more in males, rural
and poor population. (Table: 3)
% age below
-3SD Severely
Malnourished
Sex
Male
Female
Residence
Urban
Rural
Wealth Index
Lowest
Second
Middle
Fourth
Highest
Total
In children, the difference between the rich and the poor is fairly
evident in urban studies. Ramachandran, et al. studied children
from six schools in Chennai, two each from high, middle and
lower income groups.25 The prevalence of overweight (including
obese) adolescents ranged from 22% in better off schools to 4.5%
in lower income group schools. In a Delhi school with tution fees
more than Rs. 2,500 per month, the prevalence of overweight
Weight for Height
% age below
%age below
-2SD
+2SD
Thin
Overweight
6.8
6.1
20.5
19.1
1.7
1.4
5.7
6.7
16.9
20.7
2.5
1.2
8.7
6.7
6.2
5.0
4.2
6.4
25.0
22.0
18.8
16.6
12.7
19.8
1.0
1.1
1.3
2.1
2.7
1.5
was 31%, of which 7.5% were frankly obese.26 In Pune the figures
for overweight children are 24% in a well off school and 6%
in a ‘corporation’ school (unpublished data). Other studies of
Chennai and Delhi have shown that prevalence of 6.2% and 7.4%
respectively. 26 27 There is a remarkable increase in prevalence of
children with excess body fat.
15
Medicine Update 2010  Vol. 20
Great Nutritional Puzzle: Urban/Rural
and Rich/Poor divide:
Though more and more knowledge of the molecular pathways
regulating energy balance are beginning to be available still the
causes of obesity remain elusive. The pathophysiology of obesity
seems simple: a chronic excess of nutrient intake relative to the
level of energy expenditure. So obesity can result from increased
energy intake, decreased energy expenditure or a combination of
the two. However, due to the complexity of the neuroendocrine
and metabolic systems that regulate energy intake, storage, and
expenditure, it has been difficult to quantitate all the relevant
parameters (e.g., food intake and energy expenditure) over time
in human subjects.30
Today India is confronted with a grave and great nutritional
puzzle because on one hand India’s rich and urban population is
facing an epidemic of obesity, metabolic syndrome, hypertension,
cardio vascular diseases and is being projected to be the diabetic
capital of the world resulting in increased morbidity and mortality
from life style and NCDs and on the other hand India is home
to largest number of malnourished population in the world
especially the children confronting malnutrition, sanitation related,
communicable, water born and poverty diseases.
Etiology of obesity is influenced by several factors like genetic,
environmental, cultural, neuroendocrine and metabolic factors.
Genetic Factors leads to prevalence of obesity commonly seen
in families. Inheritance is usually not Mendelian. It is difficult to
distinguish the role of genes and environmental factors.Adoptees
usually resemble their biologic rather than adoptive parents with
respect to obesity, providing strong support for genetic influences.
Genetic effects appear to relate to both energy intake and
expenditure. Environmental Factors play a key role in obesity.
As evidenced by the fact that famine prevents obesity even in the
most obesity-prone individual. Cultural factors relate to both
availability and composition of the diet and to changes in the level
of physical activity in a community. Wealthier people including
women, children are more often obese. Obesity correlates to
socio economic status, time spent watching television, sedentary
life style, fast foods and traditional diets which are rich in fats
& simple carbohydrates content. Because of different life styles
and affluence, urban India is getting fatter as compared to the
rural India.
In India there is a tremendous ‘Urban/Rural’ and ‘Rich / Poor’ divide
which is further increasing in this era of globalisation resulting in
much higher prevalence of obesity in the urban rich than in rural
areas and poor communities. Complications of adult obesity are
made worse if the obesity begins in childhood. Obesity is harder
to treat in adults than in children. Women suffer from a dual
burden of malnutrition with nearly half of them being either too
thin or overweight. As undernutrition decreases, overnutrition
increases by about the same amount. Malnutrition levels are
higher among young girls. Almost half of the girls in age 15-19
are undernourished. NFHS-3 data show undernutrition declines
and overnutrition increases with age of women. The percentage
of women who are too thin is particularly high in Bihar (45%),
Chhattisgarh, and Jharkhand (43% each). Malnutrition levels are
lowest in Delhi, Punjab, and several of the small northeastern
states. The prevalence of underweight and overweight among
men shows similar variations by age, education and wealth index.
Obesity is rising in India at a worrisome rate both in adult and
child population. The relationship between obesity and poverty
is complex: being poor in one of the world’s poorest countries
(i.e., in countries with a per capita gross national product [GNP]
of less than $800 per year) is associated with underweight and
malnutrition, whereas being poor in a middle-income country
(with a per capita GNP of about $3,000 per year) is associated
with an increased risk of obesity. Some developing countries face
the paradox of families in which the children are underweight and
the adults are overweight.28
There is increased interest in the concept of a body weight “set
point” a physiologic sensing system in adipose tissue that reflects
fat stores and a receptor or “adipostat,” in the hypothalamic
centers. When fat stores are depleted, the adipostat signal
is low and hypothalamus responds by stimulating hunger and
decreasing energy expenditure to conserve energy and vice
versa.The recent discovery of the ‘ob’ gene and its product leptin
provides a molecular basis for this physiologic concept.Adipocytederived hormone leptin, is a major regulator of these adaptive
responses, which acts through brain circuits (predominantly in
the hypothalamus) to influence appetite, energy expenditure, and
neuroendocrine function. Appetite is influenced by many factors
that are integrated by the brain, most importantly within the
hypothalamus.30. Signals that impinge on the hypothalamic center
include neural afferents, hormones, and metabolites.Vagal inputs
bringing information from viscera. Hormonal signals include
leptin, insulin, cortisol, gut peptides including ghrelin, peptide YY
(PYY) and cholecystokinin. These diverse hormonal, metabolic,
and neural signals act by influencing the expression and release
of various hypothalamic peptides that are integrated with
serotonergic, catecholaminergic, endocannabinoid, and opioid
signaling pathways. Psychological and cultural factors also play
a role in the final expression of appetite. Energy expenditure
includes the following components: (1) resting or basal metabolic
Pathophysiology of Obesity:
Detailed etiology and pathophysiology of obesity is not in preview
of this chapter but a brief account is given here. In a world where
food supplies are intermittent, the ability to store excess energy
is essential for survival. Fat cells are adapted to store excess
energy efficiently as triglyceride and when needed to release
stored energy as free fatty acids. In the presence of nutritional
abundance and a sedentary lifestyle, genetic predisposition this
system increases adipose energy stores and produces adverse
health consequences. Obesity is a complex, multifactorial disease
that develops from the interaction between genotype and the
environment. Our understanding of how and why obesity occurs
is incomplete; however, it involves the integration of social,
behavioral, cultural, physiological, metabolic, and genetic factors.29
16
Is India really getting fatter- Urban Rural Divide? How to Manage Obesity?
cal training sessions are restricted or non existent in many
schools. Some schools do not have any playgrounds at all.
rate; (2) the energy cost of metabolizing and storing food; (3) the
thermic effect of exercise; and (4) adaptive thermogenesis, which
varies in response to chronic caloric intake (rising with increased
intake). Basal metabolic rate accounts for ~70% of daily energy
expenditure, whereas active physical activity contributes 5–10% 30
Thus, a significant component of daily energy consumption is fixed.
The average total daily energy expenditure is higher in obese than
lean individuals when measured at stable weight. However, energy
expenditure falls as weight is lost, due in part to loss of lean body
mass and to decreased sympathetic nerve activity.The physiologic
basis for variable rates of energy expenditure (at a given body
weight and level of energy intake) is essentially unknown.
•
Secondary causes of obesity: relate to diseases like Cushing’s
syndrome, Hypothyroidism, Insulinoma Craniopharyngioma
and Other Disorders Involving the Hypothalamus and male
hypogonadism,
One newly described component of thermogenesis, called non
exercise activity thermogenesis (NEAT), and has been linked
to obesity.30 It is the thermogenesis that accompanies physical
activities other than volitional exercise, such as the activities
of daily living, fidgeting, spontaneous muscle contraction, and
maintaining posture. NEAT accounts for about two-thirds of
the increased daily energy expenditure induced by overfeeding.
The wide variation in fat storage seen in overfed individuals is
predicted by the degree to which NEAT is induced.The molecular
basis for NEAT and its regulation is unknown.
How to Manage Obesity
The prevalence of obesity is increasing rapidly throughout most of
the developed and the developing world. Children and adolescents
are also becoming more obese, indicating that the current trends
will accelerate over time. Obesity is an independent risk factor
for increased mortality and is associated with an increased risk of
multiple health problems, including hypertension, type 2 diabetes,
dyslipidemia, degenerative joint disease, and some malignancies.
Thus, it is important for physicians to routinely identify, evaluate,
and treat patients for obesity and associated comorbid conditions.
Causes of Obesity epidemic in India:31
Along with other factors which play an important part in
pathophysiology of obesity, obesity epidemic in India has its roots
in urbanization, industrialization and drastic change in the life style
especially urban and rich who in recent years have urbanized to
western levels. Unhealthy, processed food has become much more
accessible following India’s continued integration in global food
markets.Indians are genetically susceptible to weight accumulation
especially around the waist.
Treatment of an overweight or obese person incorporates a two
step process: assessment and management. Assessment includes
determination of the degree of obesity and overall health status.
Management involves not only weight loss and maintenance of
body weight but also measures to control other risk factors.
Obesity is a chronic disease; patient and practitioner must
understand that successful treatment requires a lifelong effort.
The important components of life style changes are:
•
Unhealthy eating patterns, wrong choices of food: Traditional micronutrient rich foods are being replaced by energy dense highly processed micronutrient poor foods with
greatly increased portions ‘Dil Mange More’. High calorie
snacks, junk food revolution, cool cola (‘thanda matlab’)
colonization, and food as rewards or demonstration of love
are all part of new life styles. All celebrations and festivals
seem to be centered around rich foods.
•
Sedentary pursuits:TV and movie watching, video games, internet gazing and telephone gossip sessions are now important activities of children.TV also affects by heavy marketing
of colas and other fatty foods. The number of TV sets and
telephone connections are touted as indices of development!
Inadequate play areas: Due to unsafe roads (traffic, crime)
children are discouraged form walking or cycling to school.
Motorized vehicles are popular and they are perceived to
be quicker and safer for transport. Erosion of open spaces
for exercise and lack of parental time to supervise play are
all part of new obesogenic lifestyles. As against food as rewards, ironically exercise is meted out as a punishment ‘100 sit ups,’ ‘run round the field.’
The U.S. Preventive Services Task Force recommends that
physicians screen all adult patients for obesity and offer intensive
counseling and behavioral interventions to promote sustained
weight loss. 32 30 Following five main steps mentioned
below provide important solutions to challenges faced
in management of obesity: (1) focused obesity-related history,
(2) physical examination to determine the degree and type of
obesity, (3) comorbid conditions, (4) fitness level, and (5) the
patient’s readiness to adopt lifestyle changes.
1The Obesity Focused History: Questions directed toward weight history, dietary habits, physical activities, and
medications may provide useful information about the origins of obesity in particular patients. History of the patient
provides most important disease related information which
helps clinician to device management strategies. Obesity focused history should include questions like: What factors
contribute to the patient’s obesity? How is the obesity affecting the patient’s health? What factors lead the patient
to seek weight loss now? What is patients stress levels and
mood? What is the patient’s level of risk from obesity? What
• Obesogenic schools’ and Tution classes: An important factor for obesity in India is the intense competition for admissions to schools and colleges with flourishing tuition
classes’ right from nursery levels! Children are forced to
use their play time for additional studies. Games or physi-
17
Medicine Update 2010  Vol. 20
Table 4 : Classification of Overweight and Obesity by BMI, Waist Circumference, and Associated Disease Risk*
BMI (kg/m2)
Underweight
Healthy weight#
Overweight
Obesity
Obesity
Extreme Obesity
Obesity Class
Disease Risk* (Relative to Normal Weight and Waist Circumference)
Men <40 in (<102 cm)
> 40 in (> 102 cm)
Women <35 in (<88 cm)
> 35 in (> 88 cm)
<18.5
18.5–24.9
25.0–29.9
30.0–34.9
35.0–39.9
>40
Increased
High
I
High
Very High
II
Very high
Very High
III
Extremely high
Extremely high
* Disease risk for type 2 diabetes, hypertension, and CVD.
# Increased waist circumference can also be a marker for increased risk even in persons of normal weight.
Table 5 : A Guide to Selecting Treatment
Treatment
Diet, exercise, behavior therapy
Pharmacotherapy
Surgery
25–26.9
With comorbidities
27–29.9
With comorbidities
With comorbidities
35–39.9
+
+
With comorbidities
> 40
+
+
+
patients should have blood pressure, fasting lipid panel and
blood glucose measured at presentation. Patients at very
high absolute risk include: established coronary heart disease; presence of other atherosclerotic diseases such as
peripheral arterial disease, abdominal aortic aneurysm, and
symptomatic carotid artery disease; type 2 diabetes and
sleep apnea.
are the patient’s goals and expectations? Is the patient motivated to begin a weight management program? What kind
of help does the patient need?
BMI Category
30–35
+
+
History can very useful to suspect the cause of obesity
whether behavioral causes that affect diet and physical activity patterns or secondary causes like polycystic ovarian
syndrome, hypothyroidism, Cushing’s syndrome, and hypothalamic disease. Drug-induced weight gain by antidiabetes
agents (insulin, sulfonylureas, thiazolidinediones); steroid
hormones; psychotropic agents; mood stabilizers (lithium);
antidepressants (tricyclics, monoamine oxidase inhibitors,
paraxetine, mirtazapine); and antiepileptic drugs (valproate,
gabapentin, carbamazapine) can be detected by a thorough
history best obtained by using a questionnaire in combination with an interview.
4. Physical Fitness: It is very important to take exercise
history because several prospective studies have demonstrated that physical fitness, reported by the patient or
measured by a maximal treadmill exercise test, is an important predictor of all-cause mortality independent of BMI
and body composition. So physical activity as a treatment
approach should also be strongly emphasized.
5.Assessing the Patient’s Readiness to Change: Assessment includes patient motivation and support, stressful life
events, psychiatric status, time availability and constraints,
and appropriateness of goals and expectations. Readiness
can be viewed as the balance of two opposing forces: (1)
motivation, or the patient’s desire to change; and (2) resistance, or the patient’s resistance to change. An attempt to
initiate lifestyle changes when the patient is not ready usually leads to frustration and may hamper future weight-loss
efforts.
2. Physical Examination to Determine the Degree and
Type of Obesity: Three key anthropometric measurements are important to evaluate the degree of obesity—
weight, height, and waist circumference. The BMI is used to
classify weight status and risk of disease. (Table: 4)33 34
Waist circumference or waist-to-hip ratio measures the
excess abdominal fat which is independent risk factor for
diabetes mellitus and cardiovascular diseases. Measurement of the waist circumference is a surrogate for visceral
adipose tissue and should be performed in the horizontal
plane above the iliac crest. Cut points that define higher
risk for Asian men is >90cm and women >80cm.35 Physical
examination should include assessment of comorbid conditions and causes of secondary obesity.
Treatment
The primary goal of treatment is to improve obesity-related
comorbid conditions and reduce the risk of developing future
comorbidities.The decision of how aggressively to treat the patient,
and which modalities to use, is determined by the patient’s history,
physical examination, investigations, risk status, expectations,
and available resources. Therapy for obesity always begins with
lifestyle management and may include pharmacotherapy or
3.Obesity Associated Comorbid Conditions: The evaluation of comorbid conditions should be based on presentation of symptoms, risk factors, and index of suspicion. All
18
Is India really getting fatter- Urban Rural Divide? How to Manage Obesity?
as effective as low-fat, energy-restricted diets in inducing weight
loss for up to 1 year. Several randomized, controlled trials38 39 of
these low-carbohydrate diets have demonstrated greater weight
loss at 6 months with improvement in coronary heart disease risk
factors, including an increase in HDL cholesterol and a decrease
in triglyceride levels.
surgery, depending on BMI risk category. (Table: 5)36 Setting an
initial weight-loss goal of 10% over 6 months is a realistic target.
National Institutes of Health guidelines suggest that
nonpharmacological therapies should be attempted for 6 months
and drugs should be considered if weight loss is unsatisfactory
that is less than 0.45 kg/month. Drugs should be initiated with
the expectation that long-term use will most likely be needed.
Behavioral treatment combined with drug therapy may result in
better outcome than drug treatment alone. It is better to maintain
a moderate weight loss over a prolonged period than to regain
weight from a marked weight loss.The latter is counterproductive
in terms of time, cost, and self-esteem.
Another dietary approach is the concept of energy density, which
refers to the number of calories (energy) a food contains per unit
of weight. Adding water or fiber to a food decreases its energy
density by increasing weight without affecting caloric content.
Examples of foods with low-energy density include soups, fruits,
vegetables, oatmeal, and lean meats. Diets containing low-energy
dense foods have been shown to control hunger and result in
decreased caloric intake and weight loss.
Effective weight control involves multiple techniques and
strategies including dietary therapy, physical activity, behavior
therapy, pharmacotherapy, and surgery as well as combinations
of these strategies. Relevant treatment strategies can also be used
to foster long-term weight control and prevention of weight gain.
Alcohol consumption provides unneeded calories and displaces
more nutritious foods so it not only increases the number
of calories in a diet but has been associated with obesity in
epidemiologic studies40 as well as in experimental studies41. The
impact of alcohol calories on a person’s overall caloric intake
needs to be assessed and appropriately controlled.
Life Style Management
Three essential elements of lifestyle are: dietary habits, physical
activity, and behavior modification. Life style modifications are
essential part of obesity management and all patients must learn
how and when energy is consumed (diet), how and when energy
is expended (physical activity), and how to incorporate this
information into their daily life (behavior therapy).
Occasionally, very-low-calorie diets (VLCDs) are prescribed as
a form of aggressive dietary therapy to promote a rapid and
significant (13–23 kg) short-term weight loss over a 3–6 month
period.30 These propriety formulas typically supply 800 kcal,
50–80 g protein, and 100% of the recommended daily intake
for vitamins and minerals. Indications include well-motivated
individuals who are moderately to severely obese (BMI >30),
have failed at more conservative approaches to weight loss, and
have a medical condition like poorly controlled type 2 diabetes,
hypertriglyceridemia, obstructive sleep apnea, and symptomatic
peripheral edema that would be immediately improved with rapid
weight loss. Contraindications include pregnancy, cancer, recent
myocardial infarction, cerebrovascular disease, hepatic disease, or
untreated psychiatric disease. Side effects are fatigue, constipation
or diarrhea, dry skin, hair loss, menstrual irregularities, orthostatic
dizziness and difficulty in concentrating. Because of the need for
close metabolic monitoring, these diets are usually prescribed
by physicians specializing in obesity care. There is no scientific
evidence to validate the utility of specific “fad diets.” The main
stress should be on: Restriction, Moderation and Selection of food.
Dietary Therapy: Overall reduced caloric intake is the
cornerstone of obesity treatment. A deficit of 7500 kcal will
produce a weight loss of approximately 1 kg. The rate of weight
loss on a given caloric intake is related to the rate of energy
expenditure. With chronic caloric restriction, metabolic rate
diminishes and slows the rate of weight loss on a constant diet.
The NHLBI guidelines36 recommend initiating treatment with
a calorie deficit of 500–1000 kcal/d compared to the patient’s
habitual diet is consistent with losing approximately 1–2 lb per
week. It is important that the dietary counseling remains patientcentered and that the goals are practical, realistic and achievable.
The macronutrient composition of the diet will vary depending
on the patient’s preference and medical condition, but should
include a diet rich in whole grains, fruits, vegetables, and dietary
fiber consisting 45–65% of calories from carbohydrates, 20–35%
from fat, and 10–35% from protein. Daily fiber intake of 38 g
(men) and 25 g (women) for persons over 50 years of age and 30
g (men) and 21 g (women) for those under 50 is recommended.
Physical Activity Therapy: An increase in physical activity is
an important component of weight loss therapy.42 Although it will
not lead to a substantially greater weight loss than diet alone over
6 months.43 Exercise is an important component of the overall
approach to treating obesity. Increased energy expenditure is the
most obvious mechanism of exercise.
No medical condition has generated as many dietary remedies as
obesity.All diets have their followers, but hard data on the efficacy
of the diets are scarce. A current area of controversy is the use
of low-carbohydrate, high-protein diets for weight loss. Most lowcarbohydrate diets (e.g., South Beach, Zone, and Sugar Busters!)
recommend a carbohydrate level of approximately 40–46% of
energy. The Atkins diet contains 5–15% carbohydrate, depending
on the phase of the diet. Meta-analysis of trials37 found Lowcarbohydrate, non-energy-restricted diets appear to be at least
The impact of an exercise regimen as a sole therapy of obesity
has been difficult to document but the combination of dietary
modification and exercise is the most effective behavioral approach
for the treatment of obesity. A meta-analysis of randomized
controlled trials by the international Cochrane Collaboration
found that “exercise combined with diet resulted in a greater
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Medicine Update 2010  Vol. 20
increases total weight loss. Not every patient responds to drug
therapy.Trials have shown that initial responders tend to continue
to respond, whereas initial nonresponders are less likely to
respond, even with an increase in dosage.51 52
weight reduction than diet alone”.44 The most important role
of exercise appears to be in the maintenance of the weight loss.
Recommendation is 30 min of moderate intensity physical activity
on most and preferably all days of the week. Examples include
walking, using the stairs, doing home and yard work, and engaging
in sport activities.A regimen of daily walking is an attractive form
of physical activity.The patient can start by walking 10 minutes, 3
days a week, and can build to 30 to 45 minutes of more intense
walking at least 3 days a week and increase to most, if not all,
days.45 46 The American College of Sports Medicine recommends
that overweight and obese individuals progressively increase to
a minimum of 150 min of moderate intensity physical activity per
week as a first goal. However, for long-term weight loss, a higher
level of exercise (e.g., 200–300 min or 2000 kcal per week) is
needed. Other advantages of exercise include increases fitness,
increases insulin sensitivity, decreases blood pressure, lipids, and
calcium loss along with improving mental and physical wellbeing.
There are several potential targets of pharmacologic therapy for
obesity. The most thoroughly explored treatment is suppression
of appetite. A second strategy is to reduce the absorption of
selective macronutrients from the gastrointestinal (GI) tract, such
as fat. These two mechanisms form the basis for all currently
prescribed antiobesity agents.A third target, selective blocking of
the endocannabinoid system, has also been identified.
Drugs include
Behavioral Therapy: The principles of behavior modification
provide the underpinnings for many current programs of weight
reduction used to help change and reinforce new dietary and
physical activity behaviors. Behavior therapy provides methods
for overcoming barriers to compliance with dietary therapy and/
or increased physical activity. Typically, the patient is requested
to monitor and record the circumstances related to eating and
rewards are designed to modify maladaptive behaviors. Patients
may benefit from counseling offered in a stable group setting for
extended periods of time including after weight loss. Behavioral
treatments help obese persons to develop adaptive thinking,eating,
and exercise habits that enable them to decrease their weight
and avoid regaining weight. When recommending any behavioral
lifestyle change, have the patient identify what, when, where, and
how the behavioral change will be performed. The practitioner
must assess the patient’s motivation to enter weight loss therapy
and the patient’s readiness to implement the plan, and then take
appropriate steps to motivate the patient for treatment. Because
these techniques are time-consuming to implement, they are
often provided by ancillary office staff such as a nurse clinician or
registered dietitian. The importance of individualizing behavioral
strategies to the needs of the patient must be emphasized for
behavior therapy, as it was for diet and exercise strategies.47
•
Drugs reducing appetite or increasing satiety (appetite suppressants).
•
Drugs decreasing nutrient absorption.
•
Drugs Increasing energy expenditure.( includes ephedrine,
which is not currently approved as a treatment for obesity
in the United States)
•
Other investigational compounds
Appetite-Suppressant Medications: Appetite-suppressing
drugs, or anorexiants, act by increasing satiety and decreasing
hunger, help patients reduce caloric intake without a sense of
deprivation.
Noradrenergic Agents: Include phentermine, diethylpropion,
phendimetrazine, and benzphetamine.
All of the above medications are approved by FDA for use of “a few
weeks” only (generally 12 weeks or less) Amphetamines are no
longer recommended and approved. Side effects include insomnia,
dry mouth, constipation, euphoria, palpitations, and hypertension.
The only over-the-counter appetite-suppressant medication
approved for the treatment of obesity, phenylpropanolamine, was
recently withdrawn from the market because of concern about
an association with hemorrhagic stroke in women.
Serotonergic Agents: Fenfluramine and dexfenfluramine were
withdrawn from the market in the United States in 1997 because
of associations with valvular heart disease and pulmonary
hypertension. Some selective serotonin-reuptake inhibitors have
induced weight loss in short-term studies. Fluoxetine (60 mg) for
6 months lost more weight than those who received placebo,
steady regain occurred during the next 6 months despite the
continuation of medication. Sertraline evaluated as an adjunct
for weight maintenance after a very-low-calorie diet, showed a
similar lack of long-term efficacy.
Drug Therapy 30 36 48 49
A majority of patients who lose weight regain it.50 So the challenge
to the patient and the practitioner is to maintain weight loss.
Because of the tendency to regain weight after weight loss, the
use of long-term medication to aid in the treatment of obesity may
be indicated for carefully selected patients. Drug therapy is used
only as part of a program that includes diet, physical activity, and
behavior therapy in carefully selected patients with a BMI ≥30
or ≥27 with other risk factors or diseases.
Mixed Noradrenergic–Serotonergic Agents: Sibutramine is
an inhibitor of both norepinephrine reuptake and serotonin
reuptake that also weakly inhibits dopamine reuptake. Sibutramine
is the only anorexiant that is currently approved by FDA for
long-term use. It produces an average loss of about 5–9% of
initial body weight at 12 months and has been demonstrated to
When prescribing an antiobesity medication, patients should be
actively engaged in a lifestyle program that provides the strategies
and skills needed to effectively use the drug since this support
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Is India really getting fatter- Urban Rural Divide? How to Manage Obesity?
action that could lead to weight loss or have shown promising
results in small-scale studies in humans or animals but there
is insufficient data to provide evidence of either the safety or
the efficacy of any of these compounds as agents promoting
weight loss. Herbal compounds containing ephedra alkaloids
and caffeine are the only types for which there are data
from randomized, double-blind, placebo-controlled trials
indicating efficacy in promoting weight loss. However, all such
studies have been short-term (six months or less). Dietary
supplements containing ephedra alkaloids frequently contain
a dosage that differs substantially from that indicated on the
product label. Case reports concerning ephedra alkaloids have
noted serious CVS and CNS events including hypertension,
cardiac arrhythmia, stroke, seizure, myocardial infarction and
sudden death.
maintain weight loss for up to 2 years. Common well tolerated
mild adverse effects are headache, dry mouth, insomnia, and
constipation.A dose-related increase in blood pressure and heart
rate may require discontinuation of the medication so all patients
should be monitored closely and evaluated within 1 month after
initiating therapy. Contraindications to Sibutramine use include
uncontrolled hypertension, congestive heart failure, symptomatic
coronary heart disease, arrhythmias, or history of stroke.
Drugs That Reduce Nutrient Absorption: The only FDAapproved medication that reduces nutrient absorption is
orlistat which was approved for long term use in April 1999
and for other-the-counter use in 2007. Orlistat is a synthetic
hydrogenated derivative of a naturally occurring lipase inhibitor,
lipostatin, produced by the mold Streptomyces toxytricini.
Orlistat is a potent, slowly reversible inhibitor of pancreatic,
gastric, and carboxylester lipases and phospholipase A2, which
are required for the hydrolysis of dietary fat into fatty acids and
monoacylglycerols.The drug acts in the lumen of the stomach and
small intestine by forming a covalent bond with the active site of
these lipases. Taken at a therapeutic dose of 120 mg tid, orlistat
blocks the digestion and absorption of about 30% of dietary fat.
Orlistat has no systemic side effects because it is <1% absorbed
from the GI tract. GI side effects reported in at least 10% are
related to the malabsorption of dietary fat and passage of fat
in the feces which include flatus with discharge, fecal urgency,
fatty/oily stool, and increased defecation. Psyllium mucilloid is
helpful in controlling the orlistat-induced GI side effects when
taken concomitantly with the medication. Fat-soluble vitamins
supplements are recommended to prevent potential deficiencies.
Weight Loss Surgery
Weight loss surgery is an option for weight reduction in patients
with clinically severe obesity, i.e., a BMI >40, or a BMI >35 with
comorbid conditions.Weight loss surgery should be reserved for
patients in whom other methods of treatment have failed and who
have clinically severe obesity.36 Bariatric surgery has continually
evolved since its initial sporadic and tentative introduction in the
1950’s. The first Bariatric procedure to be preceded by animal
studies and subsequently presented to a recognized surgivcal
society and published in a peer reviewed journal was that of
Kremen and associates in 1954. (Kremen, Linner et al. 1954)
Bariatric surgical procedures reduce caloric intake by modifying
the anatomy of the gastrointestinal tract. These operations are
classified as either restrictive or malabsorptive. Restrictive
procedures limit intake by creating a small gastric reservoir with
a narrow outlet to delay emptying. Malabsorptive procedures
bypass varying portions of the small intestine where nutrient
absorption occurs.
The Endocannabinoid System: Cannabinoid receptors and
their endogenous ligands have been implicated in a variety of
physiologic functions,including feeding,modulation of pain,behavior,
and peripheral lipid metabolism. The first selective cannabinoid
CB1 receptor antagonist, rimonabant, was discovered in 1994
and was first selective CB1 receptor blocker to be approved
for use anywhere in the world. In Europe, it was indicated for
use in conjunction with diet and exercise for patients with a
body mass index greater than 30 kg/m², or patients with a BMI
greater than 27 kg/m² with associated risk factors, such as type 2
diabetes or dyslipidemia. As of 2008, the drug was available in 56
countries. On October 23, 2008, the European Medicines Agency
(EMEA) released a press release stating that its Committee for
Medical Products for Human Use (CHMP) had concluded that
the benefits of Rimonabant no longer outweighed its risks and
subsequently recommended that the product be suspended from
the UK market. It has also been withdrawn from Indian market
also. Major concern was side effects of severe depression and
suicidality.
Restrictive procedures include gastric stapling (gastroplasty),
adjustable gastric banding (wrapping a synthetic, inflatable band
around the stomach to create a small pouch with a narrow
outlet), or a combination of these two approaches. Adjustable
gastric banding is a relatively new operation that includes the
insertion of a subcutaneous reservoir so that gastric restriction
can be adjusted by means of saline injections. The procedure can
be performed laparoscopically, and the band can be removed
in an outpatient setting without anesthesia.53 Another recently
developed procedure is the vertical restrictive (sleeve) gastrectomy
in which resection of much of the gastric body leaves a narrow
tube of stomach as an alimentary conduit.
Although no recent randomized controlled trials compare
weight loss after surgical and nonsurgical interventions, data
from meta-analyses and large databases, primarily obtained
from observational studies, suggest that bariatric surgery is
the most effective weight-loss therapy for those with clinically
severe obesity. These procedures generally produce a 30–35%
Dietary Supplements & Herbal Preparations: Herbal
preparations are not recommended as part of a weight loss
program. These preparations have unpredictable amounts of
active ingredients and unpredictable, and potentially harmful,
effects.36 Some dietary supplements have mechanisms of
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Medicine Update 2010  Vol. 20
areas and poor communities. India is in the midst of an escalating
epidemic of life style disorders associated with adult as well
as childhood obesity. The important causes of the epidemic in
India appear to be: - unhealthy eating patterns, reduced physical
activity, increased sedentary pursuits and possibly `constitutional
predispositions’/ `early origins’. Prevention must begin early in
the form of a public health campaign directed towards lifestyle
changes of the family / society as a whole.The campaign requires
strong social and political will. Health professionals must think
`prevention of obesity’ at all visits, monitor BMI and ensure that
`nutrition messages’ are not conflicting and confusing.
average total body weight loss that is maintained in nearly 60%
of patients at 5 years. In general, mean weight loss is greater after
the combined restrictive-malabsorptive procedures compared to
the restrictive procedures. An abundance of data supports the
positive impact of bariatric surgery on obesity-related morbid
conditions, including diabetes mellitus, hypertension, obstructive
sleep apnea, dyslipidemia, and nonalcoholic fatty liver disease.54 55 30
Lifelong medical monitoring after surgery is a necessity.
Perioperative complications vary with weight and the overall
health of the individual. In the published literature, young patients
without comorbidities with a BMI < 50 kg/m2 who have undergone
surgery have mortality rates less than 1 percent,whereas massively
obese patients with a BMI > 60 kg/m2 who are also diabetic,
hypertensive and in cardiopulmonary failure may have mortality
rates that range from 2 to 4 percent. Operative complications,
including anastomotic leak, subphrenic abscess, splenic injury,
pulmonary embolism, wound infection, and stoma stenosis, occur
in less than 10 percent of patients.56 An integrated program that
provides guidance on diet, physical activity, and psychosocial
concerns before and after surgery is necessary. Most patients fare
remarkably well with reversal of diabetes, control of hypertension,
marked improvement in mobility, return of fertility, cure of
pseudotumor cerebri, and significant improvement in quality of
life. Late complications are uncommon, but some patients may
develop incisional hernias, gallstones, and, less commonly, weight
loss failure and dumping syndrome. Patients who do not follow
the instructions to maintain an adequate intake of vitamins and
minerals may develop deficiencies of vitamin B12 and iron with
anemia. Neurologic symptoms may occur in unusual cases. Thus,
surveillance should include monitoring indices of inadequate
nutrition. Documentation of improvement in preoperative
comorbidities is beneficial and advised.36
Standard treatment approaches for overweight and obesity must
be tailored to the needs of various patients or patient groups.
Large individual variation exists within any social or cultural
group; furthermore, substantial overlap occurs among subcultures
within the larger society. There is, therefore, no “cookbook” or
standardized set of rules to optimize weight reduction with a
given type of patient. However, obesity treatment programs that
are culturally sensitive and incorporate a patient’s characteristics
are most likely to be successful. Treatment of an overweight or
obese person incorporates a two-step process: assessment and
management. Obesity is a chronic disease; patient and practitioner
must understand that successful treatment requires a lifelong
effort.Therapy for obesity always begins with lifestyle management
and may include pharmacotherapy or surgery; depending on BMI
risk category Effective weight control involves multiple techniques
and strategies including dietary therapy, physical activity, behavior
therapy, pharmacotherapy, and surgery as well as combinations of
these strategies. Relevant treatment strategies can also be used
to foster long-term weight control and prevention of weight gain.
Obesity affects almost every aspect of life and medical practice.
The rise in obesity and its complications threatens to bankrupt the
healthcare system. Early treatment and prevention offer multiple
long term health benefits, and they are the only way towards
a sustainable health service. Doctors in all medical and surgical
specialties can contribute to manage the great Indian nutritional
puzzle of epidemic of obesity on one hand and grave danger from
undernutrition on the other.
Conclusion:
This chapter has attempted to look at the nutritional transition
that is occurring in India to answer all important question: Is India
really getting fatter – the urban/ rural divide?The demographic and
epidemiological transition, the forces of rapid urbanization and
industrialization, the changes in food consumption and physical
activity patterns that in turn are contributing to increasing
sedentarianism, definitely answers the question.Yes India is getting
fatter facing an epidemic of obesity and of other NCDs.Today India
is confronted with a grave and great nutritional puzzle because on
one hand India’s rich and urban population is facing an epidemic
of obesity, metabolic syndrome, hypertension, cardio vascular
diseases and is being projected to be the diabetic capital of the
world resulting in increased morbidity and mortality from life style
and non communicable diseases and on the other hand India is
home to largest number of malnourished population in the world
especially the children confronting malnutrition, sanitation related,
communicable, water born and poverty diseases. In India there
is a tremendous ‘Urban/Rural’ and ‘Rich / Poor’ divide which is
further increasing in this era of globalisation resulting in much
higher prevalence of obesity in the urban rich than in rural
Acknowledgement
We must appreciate the hard work done by Varun Gupta (2nd Prof.
MBBS Student, Adesh Medical College and Research Institute,
Bhatinda) in helping us with typing, editing and reviewing the
literature in an effort to present evidence based medical facts
and quality information in the chapter ‘Is India really getting fatterUrban Rural Divide? How to Manage Obesity?’
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